Alaska Workers' Compensation Board s15

ALASKA WORKERS' COMPENSATION BOARD

P.O. Box 115512 Juneau, Alaska 99811-5512

) BETHANN M. JACKSON, ) ) Employee, ) FINAL DECISION AND ORDER Claimant, ) ) AWCB Case No. 200422387, 200519911 v. ) ) AWCB Decision No. 08-0070 PROVIDENCE HEALTH SYSTEM; ) (Self-insured) Employer, ) Filed with AWCB Anchorage, Alaska ) on April 15, 2008. v. ) ) FIRST STUDENT SERVICES; ) Employer, ) ) and ) ) AMERICAN HOME ASSURANCE CO., ) Insurer, ) Defendants. ) )

We heard this claim for benefits on January 9, 2008 and closed the record at the conclusion of the hearing. Attorney Michael Jensen represented the employee. Attorney Paul Hoffman represented employer Providence Health Systems, a self-insured employer (“Providence”). Attorney Shelby Davison represented employer First Student Services and American home Assurance Company (“First Student”). BETHANN M. JACKSON v. PROVIDENCE HEALTH SYSTEM v. FIRST STUDENT SERVICES

ISSUES 1. Is the employee’s claim against Providence barred by operation of AS 23.30.100 (Notice)? 2. Is the employee’s claim against Providence barred by operation of AS 23.30.105 (Statute of Limitations)? 3. Is the employee’s claim against Providence barred by operation of AS 23.30.250 (Fraud)? 4. Is the employee’s claim against Providence barred by operation of AS 23.30.015(h) (Third Party Settlements without Written Approval)? 5. Is First Student liable for the employee’s current condition under the last injurious exposure doctrine? 6. Is the employee entitled to PPI benefits under AS 23.30.190? 7. Is the employee entitled to TTD or TPD benefits under AS 23.30.185 or AS 23.30.200, respectively, for the period from February 26, 2005 through July 30, 2005? 8. Is the employee entitled to TTD benefits under AS 23.30.185 for the period from August 1, 2005 through September 27, 2005? 9. Is the employee entitled to medical benefits, including transportation, for the period from December 27, 2004 until March 27, 2005 and the period from November 18, 2005 until 3 or 4 months later, or the end of February or March, 2006 under AS 23.30.095? 10. Is First Student entitled to reimbursement for medical expenses it paid for the time period after March, 2006? 11. Is the employee entitled to ongoing and future medical benefits under AS 23.30.095? 12. Is the employee entitled to interest on all past due benefits under AS 23.30.155(p), 8 AAC 45.140, and AS 09.30.070(a)? 13. Is the employee entitled to attorney fees and costs under AS 23.30.145(b) and 8 AAC 45.180? 14. Is either Providence or First Student entitled to attorney fees and costs under AS 23.30.155(d)?

SUMMARY OF THE EVIDENCE I. MEDICAL HISTORY The employee was injured at Providence while working at her job as a certified nursing assistant (“CNA”) on December 27, 2004. The employee stated in her deposition:

2 BETHANN M. JACKSON v. PROVIDENCE HEALTH SYSTEM v. FIRST STUDENT SERVICES

I was lifting a patient to change his briefs, and the patient was extremely large. He didn’t assist by trying to roll. He just kind of lied there. I got him on his side. I think he felt claustrophobic, because he pushed against the wall. So I pushed harder to hold him up while I was cleaning him. I felt a give in my back, and then it started to hurt….It was an immediate onset of pain.1

At hearing, the employee testified she did not immediately report this incident. She continued to work, albeit with pain.

The employee also testified about one and ½ hours later the same day, while assisting a wheelchair-bound patient, she experienced another bout of extreme low back pain when she was lowering a wheelchair to a flat position before transferring a patient from the wheelchair to the bed.2 This was the type of wheelchair that went from a chair position to a flat position. 3 She bent down to release the brakes and lower the wheelchair when her back locked up and spasmed.4 When her back spasmed, she let go of the wheelchair and the wheelchair fell back, and the top of the wheelchair hit the floor.5 The employee described the second bout of pain as similar in nature, but greater, and in about the same area of her back as she felt after the first incident when she tried to turn the heavy patient. She testified the patient on the wheelchair was not injured.6

Following this second incident, the employee reported an injury to her low back to her manager, who sent her to see Melissa Huffman, Adult Nurse Practitioner (“ANP”), Providence’s employee health manager, citing only the incident about turning the heavy patient as the probable event causing her pain.7 ANP Huffman diagnosed “back strain,” released the employee from work, and ordered physical therapy.8 When initially seen at United Physical Therapy (“UPT”) on January 3, 2005, the employee told the physical therapist that about one and ½ hours after her injury helping the obese patient, she had hurt her back when bending over to adjust and lower a

1 Employee’s deposition, 9/14/07, pg. 9. 2 Employee’s deposition, 9/14/07, pg. 60-61. 3 Id. 4 Id. 5 Id. 6 Id. 7 Providence employee injury/incident report, 12/27/04. 8 ANP Huffman clinic note, 12/27/04.

3 BETHANN M. JACKSON v. PROVIDENCE HEALTH SYSTEM v. FIRST STUDENT SERVICES wheelchair.9 ANP Huffman placed the employee on light duty until January 14, 2005, based on the recommendations of the physical therapist.10 On January 6, 2005, ANP Huffman ordered a lumbar spine x-ray, which was “essentially normal.”11 The employee returned to full duty on January 25, 2005, but was very stiff and sore by the Thursday of the first full week, and the pain lasted through the weekend.12 Physical Therapist (“PT”) Jo Young recommended continuing physical therapy two times per week for three more weeks,13 which ANP Huffman ordered.14 The February 8, 2005 PT notes show the employee was experiencing pain at a level of 6-7/10.15 On February 10, 2005, the physical therapist recommended the employee be returned to light duty for two to three weeks and continue physical therapy two times per week for three to four more weeks, as the employee’s work activities were aggravating her symptoms, that is, causing her pain and stiffness, so that she was unable to progress in her exercise program.16 On physical examination, PT Young noted the employee’s back extension was painful at 20 degrees and her back was acutely tender over L5 and L3, with muscle spasms.17 ANP Huffman restricted the employee to light duty until February 28, 2005,18 and requested authorization for four more weeks of physical therapy two times per week.19

Unfortunately, on February 18, 2005, the employee was injured when the Jeep she was driving was rear-ended by a smaller vehicle. Her vehicle, the Jeep, sustained little to no damage. 20 The employee and the three minor passengers in her car were evaluated at the emergency room.

The Providence Alaska Medical Center (“PAMC”) emergency room (“ER”) report of February 18, 2005, states: “she is complaining of pain in her low and upper back . . . . She denies any

9 UPT clinic note, 12/30/04. 10 ANP Huffman clinic note, 1/3/05. 11 ANP Huffman clinic note, 1/6/05. 12 PT Young note to ANP Huffman, 2/3/05. 13 Id. 14 ANP Huffman order, 2/7/05. 15 PT Young’s clinic note, 2/8/05. 16 PT Young’s note to ANP Huffman, 2/10/05. 17 Id. 18 ANP Huffman work restriction, 2/14/05. 19 Authorization for Additional Treatment, 3/7/05. 20 See, Photos by Claims Estimator, Carl Nelson.

4 BETHANN M. JACKSON v. PROVIDENCE HEALTH SYSTEM v. FIRST STUDENT SERVICES head or neck injury or any other injury.”21 In her report dated March 3, 2005, PT Young also noted the increased symptoms of “intermittent pain and stiffness in her mid to lower back and rates her pain from 0-4/10.” Her notes also reflect the employee’s immediate complaints from the accident were “tension between her shoulder blades and a headache.” At hearing, the employee testified she felt mostly pain in her neck and shoulders but also testified that she advised the attending personnel she had a low back condition. She further testified her neck and shoulder pain receded quickly and her low back was mostly unaffected by the accident. She also testified she missed three days of work. The employee testified she received physical therapy for her upper back pain at UPT, but those records were kept separate from the physical therapy she was continuing to receive at UPT for the lower back pain due to the work injury at Providence.22 The clinic note of Richard Ervin, ANP of Anchorage Neighborhood Health Center shows ANP Ervin ordered physical therapy for her mid back pain, and that the employee’s low back pain was already being treated with physical therapy.23 On the November 23, 2005 questionnaire the employee completed at her first visit at the Alaska Spine Institute (“ASI”), she wrote she had an automobile accident injury in February of 2005, which had resulted in upper thoracic tenderness.24

On or about February 21, 2005, the employee was terminated from her job at Providence due to frequent absences and tardiness, many instances of which were due to her low back condition.25 After her termination, the employee continued her treatment with ANP Huffman and physical therapy with PT Young.

On March 8, 2005, PT Young noted the employee was “feeling pretty good” and was progressing as expected, since she was on light duty.26 On March 31, 2005, PT Young noted the employee was progressing well, but was still unable to perform activities she tolerated before her injury, such as treadmill running, swimming, and martial arts, without aggravating her

21 PAMC ER report, 2/18/05. 22 Employee’s 9/14/07 deposition, pg. 80. 23 ANP Ervin’s clinic note, 3/2/05. 24 ASI Questionnaire, 11/23/05. 25 Employee’s deposition, 9/14/07, pg. 16. 26 PT Young clinic note, 3/8/05.

5 BETHANN M. JACKSON v. PROVIDENCE HEALTH SYSTEM v. FIRST STUDENT SERVICES symptoms, and she was still susceptible to re-injury.27 On physical exam, PT Young noted the employee had pain on extension of her lumbar spine at 20 degrees, depending on previous activity.28 The physical therapy ordered continued physical therapy for two times per week for three to four more weeks, which ANP Huffman ordered.29 On April 4, 2005, PT Young recommended another 3 to 4 weeks of physical therapy, 2 times per week, which ANP Huffman ordered.30

On May 6, 2005, a magnetic resonance imaging (“MRI”) of the employee’s lumbar spine was performed at ANP Huffman’s request. David Moeller M.D., made the following findings: These images demonstrate central L4-5 disk protrusion with mild canal stenosis. Central L5-S1 disk protrusion also present and again with mild canal stenosis. The other lumbar disks are normal in configuration and signal intensity. The lateral recesses and neuroforamen remain widely patent. Bone marrow signal intensity is normal. No other abnormality is demonstrated. Impression: Central L4-5 and L5-S1 disk protrusions with mild canal stenosis at both levels.31

The employee continued with her physical therapy until she was discharged on May 24, 2005. The PT note for May 24, 2005 states the employee’s back was sore after she did the Torch Run, which she mostly walked, and also notes her back was painful on extension to 20 degrees.32

The employee was seen by ANP Ervin on June 29, 2005, when she reported her back was okay if she kept active.33 On her September 7, 2005 visit to ANP Ervin, she complained of having back pain, for which she got good relief taking Doan’s pills.34

The employee underwent a pre-hire physical report before being cleared for hire at First Student in September 2005. The pre-hire physical report stated that the employee’s back was within

27 PT Young clinic note, 3/31/05. 28 Id. 29 Authorization for Additional Treatment, 4/4/05. 30 UPT Workers Compensation Authorization for Further Treatment, 4/4/05. 31 MRI, 5/6/05. 32 PT notes, 4/6/05 to 5/24/05. 33 ANP Ervin clinic note, 6/29/05. 34 ANP Ervin clinic note, 9/7/05.

6 BETHANN M. JACKSON v. PROVIDENCE HEALTH SYSTEM v. FIRST STUDENT SERVICES normal limits.35 In September 8, 2005, employee was hired by First Student as a bus attendant.36 On October 19, 2005, the employee was seen at Patients First Medical Clinic for low back pain, which she stated she thought was “irritation of a previous injury.”37 The employee complained of low back pain with pain radiating into her right buttock, but no pain below the knee.38 The employee also stated she had had similar pain in the past.39 She was prescribed a muscle relaxant and pain medication.40

On November 18, 2005, the employee sustained the final injury in relation to this claim. The employee testified she was bent over to trying to restrain a young special needs student and her lower back locked up the way it had when she lowered the wheelchair [at Providence].41 The employee said she felt extreme pain, again in the area of her low back where she originally felt such symptoms while turning the heavy patient at Providence. She returned to the Patients First Medical Clinic where she was seen for low back pain and prescribed Ultracet, Soma, Ice and advised to get physical therapy and avoid heavy lifting.42

The Patients First Medical Clinic report dated November 22, 2005, called the event an exacerbation of her low back pain and referred her to Alaska Spine Institute where she came under the care of Shawna Wilson, ANP, who ordered an MRI which was interpreted by Harold Cable, M.D.

In his report dated November 23, 2005, Dr. Cable diagnosed: Significant disc degeneration, particularly at L4 and L5. There is what appears to be central herniations at each of these levels, the larger at L4-5. Fortunately, the canal is rather wide and there is no obvious apparent stenosis of the canal, nor is there obvious compression or displacement of the nerve roots.

35 Physical Examination for Alaska School Bus Attendant, David Popken, PA-C, 9/6/08. 36 First Student Hearing Brief, 1/11/08. 37 Patients First Medical Clinic Report, 10/19/05. 38 Id. 39 Id. 40 Id. 41 Employee deposition, 9/14/07, pgs. 21-22. 42 Patients First Medical Clinic Report, 11/18/05.

The MRI report noted disc space narrowing at L4 and L5, and decreased signal intensity at each of these levels.43

ANP Wilson diagnosed the employee with discogenic low back pain secondary to herniated nucleus pulposus at L4-L5 and L5-S1, with referral pain into the right lower extremity without frank radiculopathy.44 She noted the employee reported that her low back pain started in December of 2004 after lifting a patient at Providence and she was treated conservatively with improvement, but her symptoms did not completely abate.45 She continued the employee on her medications and placed her in physical therapy 3 times a week for a month.46

The employee was released to modified work as a dispatcher for Student First on November 30, 2005.47 The employee continued to work for Student First in this capacity. She also continued to treat with ANP Shawn Wilson and also participated in physical therapy at UPT with PT Young. In her December 12, 2005 clinic note, ANP Wilson found the employee’s condition improving with no leg symptoms.

On January 23, 2006, ANP Wilson found ongoing improvement with continued conservative care.48 Specifically, she found the employee had good range of motion of the lumbar spine and negative straight leg raising bilaterally.49 ANP Wilson recommended continued conditioning / therapy and weight loss.50 She stated she believed a large part of the employee’s improvement was due to her not bending or lifting repetitively, and she also doubted the employee would be able to return to a heavy capacity employment.51 Both the employee and her boyfriend testified she has gained a significant amount of weight since the injuries at Providence because of her more restricted lifestyle.

43 MRI report, 11/23/05. 44 ANP Wilson clinic report, 11/23/05. 45 Id. 46 Id. 47 Employee deposition, 9/14/07, pg. 25. 48 ANP Wilson clinic note, 1/23/06. 49 Id. 50 Id. 51 Id.

The employee continued with physical therapy at UPT. A review of PT Young’s notes, although difficult to read, reveal the employee reported lower back pain level was zero on some visits, 2 to 3 on other visits, sometimes with spasms.52 PT Young’s progress note of March 31, 2006 noted the employee had had flare ups on 3 to 4 occasions, after walking for long periods.53 She recommended 4 to 6 more weeks of physical therapy.54 On April 12, 2006, PT Young recommended the employee reduce her externship hours to 4 hours per day and avoid bending or lifting more than 15 to 20 pounds, stating 8 hours a day was aggravating her lower back symptoms.55 In her April 28, 2006 progress report, PT Young stated the employee complained of muscle spasms in her lower back that morning.56 PT Young noted the employee’s symptoms had been improving since she completed her externship on April 26, 2006.57 On physical exam, PT Young found it was painful for the employee to extend her lumbar spine to 15 degrees.58 She recommended 4 to 6 weeks more physical therapy.59

Although the employee’s progress continued, ANP Wilson noted a set-back in her May 1, 2006 note which indicates the employee’s externship for her medical assistant specialist (“MAS”) certification (working long hours) caused an increase in her low back pain.60 The employee had had to use more medication during her externship, but was able to reduce that use when the externship was completed.61 On exam, ANP Wilson noted restricted range of motion of the lumbar spine in all planes, with increasing pain with any extension or rotary-type movements over the L4-L5 and L5-S1 facets, greater on the right than the left. 62 ANP Wilson diagnosed discogenic low back pain with herniated nucleus pulposus at L4-5 and L5-S1 and obesity. 63 She ordered additional physical therapy for six weeks, exercise, weight loss, and prescribed Ultram.64

52 UPT clinic notes, 1/06-5/06. 53 PT Young’s progress note, 3/31/06. 54 Id. 55 PT Young’s 4/12/06 note. 56 PT Young’s progress note, 4/28/06. 57 Id. 58 Id. 59 Id. 60 ANP Wilson clinic note, 5/1/06. 61 Id. 62 Id. 63 Id. 64 Id.

By August, the employee was much improved. In her August 30, 2006 report, ANP Wilson noted the employee was symptom free unless she was subjected to extended periods of standing or walking. The employee was no longer on pain medication and she had been increasing her activity levels to include biking, swimming and tai-chi classes.

In November of 2006, the patient called to complain of increased back pain and stiffness after starting a new job and to request medication.65 The patient mentioned she was continuing with physical therapy.66 Relafen was prescribed the next day.67

In January 17, 2007, ANP Wilson reevaluated the employee who was by then employed as a medical assistant specialist (“MAS”) working 50 hours per week.68 She noted the employee’s low back pain waxed and waned depending on activity. The employee reported a deep ache in her low back with some muscle spasm at the end of the day. 69 On physical exam, ANP Wilson noted obvious spasm of the paraspinal muscles bilaterally and restricted range of motion with forward flexion.70 She further stated the employee seemed stable and her current symptoms were a permanent aggravation of her preexisting disc injury.71 A permanent partial impairment (“PPI”) rating evaluation was scheduled with Michael James, M.D.

On March 29, 2007, Dr. James performed a PPI rating on the employee. 72 Dr. James found the employee medically stable and stated the PPI would be “best defined using the Range of Motion (“ROM”) model as she has two-level disc pathology.”73 Dr. James measured the employee’s lumbar spine range of motion according to the AMA Guides to Evaluation of Permanent Impairment,74 (“AMA Guides”), as follows:

65 ASI clinic note, 11/16 & 17/06. 66 Id. 67 Id. 68 ASI clinic note, 11/15 & 17/06. 69 ANP Wilson clinic note, 1/17/07. 70 Id. 71 Id. 72 Dr. James PPI rating, 3/29/07. 73 Id. 74 AMA Guides to Evaluation of Permanent Impairment 5th Edition, 2001, American Medical Association Press.

The patient demonstrates 55° lumbar flexion, 8° lumbar extension, 17° left lateral bending, 22° right lateral bending. Straight leg raising is 98° on the right, 71° on the left (total sacral motion is 76° and therefore this is invalid[sic]75).

Dr. James proceeded to describe the manner in which he performed the PPI rating as follows: a. Using table 15-7, the patient is a IIc, which is 7% impairment of the whole person. b. Range of motion: lumbar flexion of 55° is 2% impairment, lumbar extension of 8° is 5% impairment, left lateral bending of 17° is 2% impairment, right lateral bending of 22° is 1% impairment. This is added for a 10% impairment of the whole person. c. There is no loss of sensation or strength that can be identified today and so these are rated at 0. d. Using combined value tables, 7 + 10 = 16% impairment of the whole person.76

Dr. James explained in detail the method by which he performed the employee’s PPI rating at his deposition on December 19, 2007.77 Dr. James explained that he used the accessory validity test on page 406 of the AMA Guides to determine whether the ROM method would be valid in the employee’s case.78 He stated based on lumbosacral motion of 76° and straight leg raising of 71° on the left by inclinometer, the test was valid.79 At his December 19, 2007 deposition he also corrected the typographical error concerning the accessory validity test on his March 29, 2007 report.80 Although the March 29, 2007 report stated the test was invalid, it was in fact valid.81

Dr. James also explained at his deposition that according to his interpretation of the AMA Guides, using the ROM method is appropriate where there is multi-level involvement, or recurrent disc herniation.82 Dr. James stated his interpretation of the language on page 380, No.

75 At Dr. James Deposition on 12/19/07, on pages 20-21, Dr. James corrected the “invalid” to “valid,” stating it was a typo. He further stated, ”[B]ecause the straight-leg raising was 71 degrees. Sacral motion was 76. So if you’re using the range of motion model, that’s valid.” For a more complete explanation, see section on Dr. James 12/19/07 deposition, below. 76 Dr. James PPI rating, 3/29/07. 77 Id. 78 Dr. James Deposition, 12/19/07, at 56. 79 Id., at 88-93. 80 Id., at 56. 81 Id. 82 Id., at 97-99.

2 of the AMA Guides is that the requirement of the presence of radiculopathy pertains to stenosis, not disc herniations. The AMA Guides read as follows: The ROM method is used in several situations: …. 2. When there is multilevel involvement in the same spinal region (eg, fractures at multiple levels, disk herniations, or stenosis with radiculopathy at multiple levels or bilaterally. ….83 Use the ROM method if: …. d. there is recurrent disk herniation or stenosis with radiculopathy at the same or a different level in the same spinal region.84

Dr. James also testified concerning the flow chart or algorithm, that demonstrates the decision making process for choosing the diagnostic related estimate (“DRE”) method versus the ROM method.85,86 Where the injury is determined to be single level, the decision maker is directed to choose the DRE method, and the ROM method if it is more than a single level injury.87,88

At the December 19, 2007 deposition, Providence questioned Dr. James in great detail on why he chose the ROM method rather than the DRE method: Q: So then the DRE method would be the methodology that you should use, unless something takes it out of that methodology? A: Right. And several-level involvement is. Q: But she didn’t have several-level involvement with— A: No— Q: --radiculopathy? A: No, she – she’s got radiculopathy, and she’s got two-level involvement. Now — Q: She has radiculopathy? A: Well, she did have radicular signs. Q: Okay. But that’s different that radiculopathy, is it not? A: I guess it’s a matter of semantics you could say, yeah. She has two-level herniation. Annual tears are herniation. It’s just a matter of degree. Q: All right. But it says “disc herniations with radiculopathy.”

83 AMA Guides, 15.2, page 380. 84 Id., 15.2a, page 380-381. 85 Id., Figure 15-4, page 380. 86 Dr. James’ 12/19/07 deposition, page 21. 87 Id., Figure 15-4, pg. 380. 88 Dr. James’ 12/19/07 deposition, page 21.

A. Okay. On page 380, No. 2, at the top, left-hand corner, there is “When there’s multi-level involvement in the same spinal region, i.e., fractures, comma -- fractures at multiple levels, comma, disc herniations, comma, or stenosis with radiculopathy at multiple levels or bilaterally. Okay. So they seem to make the distinction – at least in that sentence they make the distinction between fracture, disc herniations, and stenosis with radiculopathy. At least that’s the way -- Q: You’re reading-- A: When they put the commas, that usually closes the thought pattern, doesn’t it? Q: But if you look down at 4-D, where it talks about the “use of range of motion if,” there’s not that comma, is there? A: You know, I kind of feel like a rabbi reading a Talmud. We’re arguing about nuances here. And I think – it’s like may and well and shall, isn’t it?89

Providence made an issue of the fact that in the sentence on page 380 of the AMA Guides, section 15.2, number 2, there was a comma after disc herniations, whereas in section 15.2a, number 4, item d, there was not a comma, and argued that to use the ROM method, there must be radiculopathy. Dr. James argued that according to the AMA Guides, the two-level disc herniation suffered by the patient did not have to be accompanied by radiculopathy to be evaluated by the ROM method, rather, the requirement for radiculopathy referred to stenosis.

Providence also questioned Dr. James about the definition of radiculopathy, as follows: Q: Did she have pain that was in the distribution of a nerve root? A: That’s what I say. Buttock pain is from an L5 root…. Q: This is based on your saying that you are going to follow what you understand to be the nerve roots -- or the distribution of a nerve root as opposed to what the AMA guides say; isn’t that correct? A: This is not written in stone. You must understand that this is a dermatomal map. These vary depending upon the book you choose. And this is one example of that. I’m sure that the people who put this in will say the very same thing. I think any intelligent, educated person in medicine will tell you that. Sorry.90 Q: With regard to radiculopathy, that is defined in the AMA guides, is it not, at page 382? A: It’s on – yeah. Q: And, once again, your difference between yourself and Dr. Yodlowski in this area is that she testified that buttocks pain is from – is not from L4 or L5 or L5- S1? A: Well, where does it come from? Q: Based on –

89 Dr. James 12/19/07 deposition, pgs. 96-98. 90 Dr. James 12/19/07 deposition, pgs.86-87.

A: If she’s using that chart and that’s all she’s relying on, she doesn’t treat backs. I don’t know what she does for a living, but she certainly doesn’t treat backs. Q: Okay. A: If your’ using that as an example, her conclusion I think – that there is some – it’s quite unusual that someone who treats backs would say that. Q: So you differ with her on that opinion, that there was – because you’re saying -- …. THE WITNESS (Dr. James): That’s fine. But L5 distribution is people come in complaining of buttock pain and hip pain both. Very typical.91

Dr. James also testified as to the PPI rating he would give the employee under the DRE method.92 He stated that using the DRE method, the employee would be categorized at Roman numeral II-C, which is 5-8 percent.93 Dr. James stated she would have a 5-8% impairment under the DRE method based on her injury to her intervertebral discs, non-verifiable radicular complaints, and asymmetric loss of range of motion, referencing Lumbosacral Category No. II, page 384 of the AMA Guides.94,95 The AMA Guides direct the evaluator as follows: “[I]n the small number of instances in which the ROM and DRE methods can both be used,” evaluate the individual with both methods, and award the higher rating.”96

At Providence’s request, on April 16, 2007, the employee saw Marilyn Yodlowski, M.D., an orthopedic surgeon, for evaluation and a PPI rating.97 Dr. Yodlowski diagnosed the employee with: 1. History of low back pain with no neurological deficits, chronic with episodic symptomatic exacerbations. 2. Lumbosacral sprain/strain secondary to the work event of December 27, 2004, resolved with no impairment. 3. Lumbosacral sprain/strain secondary to the work event of November 18, 2005, resolved with no impairment. 4. Lumbosacral sprain/strain secondary to the motor vehicle accident of 2/18/05, resolved with no impairment

91 Id., pgs. 99-100. 92 Id., pages 22-25. 93 Id., page 22-24. 94 Dr. James 12/19/07 deposition, pg. 25. 95 Id., pg. 84. 96 AMA Guides, pg. 380. 97 Dr. Yodlowski’s EME report, 4/16/07.

5. Degenerative disease of the lumbosacral spine, including degenerative disc disease and facet arthritis/arthropathy, pre-existing and unrelated to the work event of 12/27/04. 6. Obesity. 7. Crohn’s disease. 8. Depression and question of “borderline personality.”98

Dr. Yodlowski opined the employee’s underlying pathologic condition of degenerative disease of the lumbosacral spine was the substantial cause of her chronic and ongoing low back pain.99 She further stated the December 27, 2004 work injury was caused by a lumbosacral sprain/strain that would have resolved in about three month’s time.100 Dr. Yodlowski stated the motor vehicle accident that occurred on February 18, 2005 caused a new, acute lumbosacral sprain/strain superimposed on the almost resolved work injury as well as the chronic underlying degenerative disease of the lumbosacral spine, and after February 18, 2005, only a very minimal resolving component of the employee’s back condition was due to the work injury of December 27, 2004.101 She also stated at the time of the November 18, 2005 work injury, the low back sprain/strain from the December 27, 2004, work injury had long since resolved, and there was no causal connection between the events.102 Dr. Yodlowski opined the employee’s work injury of December 27, 2004 caused only a temporary exacerbation of symptoms from the pre-existing degenerative changes of her lumbosacral spine and after February 18, 2005, the employee would have needed only one month’s additional physical therapy due to the December 27, 2004 work injury.103

Dr. Yodlowski stated the work injury of November 18, 2005 was not the substantial cause of any disability or need for medical treatment beyond her initial disability and need for medical treatment.104 She opined the November 18, 2005 work injury was also a lumbosacral sprain/strain that would have resolved three months after the injury.105

98 Id., pg. 7 99 Id. 100 Id. 101 Id. 102 Id., pg. 8. 103 Id. 104 Id. 105 Id.

Dr. Yodlowski stated the employee was medically stable, and probably had been medically stable as far as the December 27, 2004 work injury is concerned, since the end of March, 2005.106 Dr. Yodlowski performed a PPI rating on the employee using the AMA Guides, 5th edition, stating the employee’s December 27, 2004 work injury impairment fell into the DRE Lumbar Category I, 0% impairment of the whole person, according to Table 15-3 on page 384, as in Dr. Yodlowski’s opinion the employee had no documentable neurologic impairment, no documented alterations in structural integrity, and no other indication of impairment related to injury, and no fractures.107

At her October 31, 2007 deposition, Dr. Yodlowski explained in more detail her choice of the DRE method to rate the employee’s impairment.108 She opined the employee did not have two- level disc herniations, but rather had multi-level findings on an MRI.109 She stated she thought MRI findings of disc herniation must be correlated with a radiculopathy to be considered an impairment.110 Dr. Yodlowski stated she placed the employee in DRE Lumbar Category I as she had no significant clinical findings.111 She stated she did not place the employee in DRE Lumbar Category II as the employee did not have muscle guarding or spasm, nor did she have asymmetric loss in range of motion, which Dr. Yodlowski defined as having a muscle spasm that pulls you to the side when bending forward or flexing back.112

Dr. Yodlowski stated that the employee did not have radiculopathy, as she did not think the employee’s complaints of right buttock pain or pain going into the right lower extremity were “nonverifiable radicular complaints” as the pain was not in a nerve root distribution, in her opinion.113 Dr. Yodlowski conceded that other doctors might agree that the employee’s complaints of right buttock and right lower extremity pain is a radiculopathy.114

106 Id., pg. 9. 107 Id. 108 Dr. Yodlowski’s 10/31/07 deposition. 109 Id., pg. 28. 110 Id., pg. 32-33. 111 Id., pg. 30-31. 112 Id., pg. 32. 113 Id., pgs. 102-103. 114 Id., pg. 104.

In addition, Dr. Yodlowski stated the employee has the permanent physical capacity to perform the work encompassed within the job of CNA or bus attendant from May 24, 2005 to November 18, 2005, and two months after November 18, 2005.115 She stated any limitations beyond that point would be “due to a combination of her pre-existing and progressive degenerative disease of the lumbosacral spine, her general level of deconditioning and obesity, none of which are due to either work injury.116 Therefore, she opined the work injury of December 27, 2004 was not a substantial cause of the employee’s inability to perform her CNA or bus attendant jobs after November 18, 2005, nor was the work injury of November 18, 2005 the substantial cause of her being unable to perform those jobs three months after November 18, 2005.

II. PROCEDURAL HISTORY

A. PROVIDENCE The employee filed a Report of Occupational Injury or Illness (“ROI”) for her work injury at Providence on December 27, 2004.117 On or about February 21, 2005, Providence terminated the employee for excessive absences.118 On June 1, 2005, Providence closed the claim.119

The employee testified at hearing that she was unfamiliar with the workers’ compensation system. Seeking payment of her continuing medical costs, and being unfamiliar with the workers’ compensation system the employee filed a small claims action on December 28, 2006.120 The suit was dismissed in May, 2005 on summary judgment for lack of jurisdiction over a workers’ compensation claim. The employee was ordered to pay defense costs of over $300, which she did. Ironically, in its Motion for Summary Judgment, Providence alleged it had paid TPD benefits. According to the affidavit of Ann Pence, Providence’s compensation manager, as of May 3, 2005, Providence paid the employee the value of $2,618.61 in TPD and medical benefits. Ms. Pence later retracted her statement that TPD had been paid. No compensation report was filed

115 Dr. Yodlowski’s EME report, pg. 11. 116 Id. 117 ROI, 12/27/04. 118 Employee’s 9/14/07 Deposition, pg. 16. 119 Pence Affidavit, 5/3/07, pg. 2. 120 Employee’s Hearing Brief, 12/31/07, pg.

17 BETHANN M. JACKSON v. PROVIDENCE HEALTH SYSTEM v. FIRST STUDENT SERVICES based on our review of the Board’s file. Michael Jensen, the employee’s attorney confirmed this. Ms. Pence was not called to testify.

On January 8, 2007, the employee filed a Workers’ Compensation Claim (“WCC”) for her work injury at Providence, requesting payment of compensation benefits. Providence filed an Answer to the employee’s WCC, admitting that it owed medical benefits, but denying TTD, vocational rehabilitation, attorney’s fees and costs, penalty, interest and transportation costs.

Providence filed its first controversion dated May 9, 2007, denying medical benefits after May24, 2005.121 It filed another controversion dated June 8, 2007, denying medical benefits after March 27, 2005.122 Providence filed a third controversion dated September 21, 2007, denying all benefits based on AS 23.30.100, AS 23.30.105 and AS 23.30.250.123 In addition, Providence filed a second amended Answer denying benefits pursuant to AS 23.30.015(h).124

B. MOTOR VEHICLE ACCIDENT On July 5, 2005, the employee signed a full release of claims against the defendant in her motor vehicle accident in exchange for a lump-sum of two thousand three hundred dollars ($2,300.00). The settlement document the employee signed was a mere one page form that did not outline the injuries or damages sustained in the accident.125

C. FIRST STUDENT On May 2, 2007, the employee filed a WCC against First Student.126 Northern Adjustors, Inc. filed an answer denying benefits.127 Subsequently, First Student’s Adjustor did pay the employee

121 Providence’s controversion, 5/9/07. 122 Providence’s controversion, 6/8/07. 123 Providence’s controversion, 9/21/07. 124 Providence second amended Answer, 125 Based on this settlement, Providence argues the employee’s workers’ compensation claim against it must be barred under AS 23.30.015(h) of the Act because she did not get Providence’s written approval prior to settling. 126 First Student’s Hearing Brief, 1/11/08, pg. 1. 127 Id.

TTD for two days, transportation costs, and medical costs for treatment at Alaska Spine Institute from December 12, 2005 through April 27, 2007, and United Physical Therapy for dates in December, 2005, and January, February and March of 2006.

III. HEARING AND DEPOSITION TESTIMONY

A. TESTIMONY OF BETHANN (HAWLEY) JACKSON The employee, Bethann (Hawley) Jackson, testified in person on her own behalf. She also testified in her deposition taken on September 14, 2007. The following summary of the employee’s recollection of events is taken mostly from her hearing testimony, except when identified specifically as her deposition testimony.

The employee is now 28 years old, with two children, and is currently employed as an MAS, which she said is less physically demanding than her prior work at Providence as a Certified Nursing Assistant (“CNA”) or as an Emergency Medical Technician (“EMT”) which she performed before then. Although she finds her current work fulfilling, she testified her back condition still makes it difficult to perform without pain.

Concerning her work injury at Providence, the employee testified the obese patient she was assisting when she hurt her back at Providence in December of 2004 was a patient others had hurt themselves assisting. She said she requested assistance to change the patient’s briefs, which were soiled, but the other CNA and nurse from whom she requested assistance were unable to help her. She said she then asked the nurse manager to help her, but the manager told her she had to do it herself or wait until after lunch, which was about 3 and ½ hours later, when the manager would have time to assist. The employee testified she did not want to leave the patient in his soiled briefs for that length of time, so she changed his briefs on her own. She stated she hurt her back when rolling the patient to change his briefs, as noted above in the medical history. About one and ½ hours later, when she was assisting another patient in a wheelchair, her back “locked up” and she had another onset of pain, at a level of 12 on a scale of 1 to 10. She testified she told Mary, an LPN on the unit where she worked, that she had hurt her back with the first patient, and later her back locked up with another resident. She stated she felt the injury

19 BETHANN M. JACKSON v. PROVIDENCE HEALTH SYSTEM v. FIRST STUDENT SERVICES happened at the first incident when rolling the obese patient, and the second incident with the wheelchair, and the work injury at First Student, were both her back telling her “you’ve pushed beyond what I can do.”

In regards to her health care providers, the employee testified ANP Huffman, the health care provider who treated her for her low back condition after the December 2004 injury, did not do a thorough physical exam. She said Dr. James performed the most thorough physical exam of all the health care providers who saw her. She also stated ANP Huffman told her she had a muscle sprain and would be fine. She said the May 2005 MRI was performed because PT Young and ANP Huffman were concerned she had undergone a long period of physical therapy without improvement. She further testified she did not find out about the results of the May 2005 MRI until the end of June, 2005, when the insurance adjustor told her the MRI showed a “central protrusion” and that central protrusions usually do not cause any problems. The employee testified she never heard from ANP Huffman concerning the MRI. Therefore, the employee stated she understood she did not have a permanent back problem. She did not realize she had a serious back problem until November 2005, when ANP Wilson explained to her that protrusions were herniations, and there were restrictions on her activities.

Before the events in question, the employee testified she had a very active lifestyle, never had any back pain, and was never treated for low back pain. She stated she tried to go hiking in 2005, but the activity bothered her back. She also stated she is unable to do many of the activities, such as bike riding and martial arts she used to do before the 2004 work injury. The employee testified she has an identical twin sister who has no low back problems to her knowledge.

In early December 2004, the employee applied and was accepted into a part-time program to become an MAS through the Career Academy. The classes were to meet for about six weeks from 6:00 to 10:00 in the evening for six weeks in February and March. The employee testified she intended to continue her work full-time while attending classes at the Career Academy.

The employee testified her back pain level was about a 3-4/10 before she had her motor vehicle accident on February 18, 2005.128 She said she had tightness and extreme discomfort in her upper back and neck after the accident, but no increase in her low back pain.129 She said she was treated with physical therapy for her upper back pain.130

On or about February 24, 2005, the employee testified that she was terminated from her employment at Providence for excessive absences. The employee admits in her deposition that some of the absences were related to the needs of her children, but most were caused by her inability to work because of back pain. Time sheets from Providence reflect these reasons for the employee’s tardiness and absences from work, and at hearing the employee corrected some of those entries to indicate more were related to her back pain than is reflected in the time sheets. Her pain level in her back was about a 3 or 4 on a scale of 1-10 at the time she was terminated. 131 The employee testified she requested emergency family medical leave or even leave without pay to avoid losing her job.132 She was told to come to work or be fired.133

After the employee was terminated she sought and obtained unemployment benefits from February 26 through July 30, 2005.134 After her termination, the employee testified, she was in financial difficulty and did not want to incur medical bills. Eventually, the employee applied and received Medicaid assistance.

The employee stated her back pain was at a level of 2 when she went to work at First Student.135 She admitted she filled out the pre-employment form at First Student stating her back was within normal limits, but she explained this was because she was still unaware she had a significant back problem with restrictions on her activities, as this had never been explained to her by ANP Huffman. She testified her back pain increased drastically, up to a 12, with the work injury at

128 Employee’s Deposition, 9/14/07, pg. 19. 129 Id., 19-20. 130 Id. 131 Employee’s Deposition, 9/14/07, pg. 18. 132 Id., pg. 17. 133 Id. 134 Unemployment Insurance Decision Regarding Eligibility dated 3/10/05. 135 Employee’s 9/14/07 deposition, pg. 20.

First Student on November 18, 2005, but this decreased to a level of 2 to 3 by March of 2006. She testified her back has still not returned to the condition it was before the December 27, 2004 work injury at Providence. She said she still uses medication for her back pain, including Relafen daily and Flexeril about once per month.

The employee testified as to the level of pain she experienced in her lower back over time. She stated the Self-Reported Pain Level Table that is attached to Dr. James’ December 19, 2007 deposition as Exhibit D is an accurate reflection of her pain. The table shows the employee had no pain prior to her December 27, 2004 injury, then after the first incident on December 27, 2004 her pain was at a level of 7 on a scale of 1-10, then up to a level of 12 after the second incident on that same day. By the next day, her pain level was down to 8 to 9, where it stayed through January 4, 2005. From January 5th through January 25th, 2005, the pain as down to 2 to 3. From January 26th through the middle of February, 2005, the pain was at 2 to 4. From the end of February through August of 2005, it was at a level of 2. On November 18, 2005, the date of the injury at First Student, the pain was at a level of 12, but by the next day it was down to 7 to 8, where it stayed until February of 2006. From March 2006 until the present, the pain is at a level of 2 to 3. In addition, the employee stated she did have pain radiating to her buttocks prior to October 2005, as is noted in a clinic visit note of October 19, 2005 at Patients First Medical Clinic.

B. DEPOSISTION TESTIMONY OF J. MICHAEL JAMES, M.D. J. Michael James, M.D., testified by deposition on December 19, 2007. Dr. James stated he was a graduate of the University of Washington School of Medicine and his residency was in physical medicine and rehabilitation.136 He is board certified in physical medicine and rehabilitation, electrodiagnostic medicine and interventional pain management.137 Dr. James has practiced in Anchorage exclusively in these areas of medicine since 1973.138 Ninety percent of what Dr. James does is non-surgical spine care.139 He also testified he is a former chairman of the

136 Dr. James Deposition,12/19/07, pg. 5-6. 137 Id. 138 Id. 139 Id.

22 BETHANN M. JACKSON v. PROVIDENCE HEALTH SYSTEM v. FIRST STUDENT SERVICES department of medicine at Providence Hospital and former chief of staff at Providence Hospital.140 In addition, he has taken courses in PPI rating and he himself used to teach PPI rating.141

Dr. James was questioned by First Student concerning the employee’s first visit at Alaska Spine Institute on November 23, 2005.142 Although Dr. James did not see the employee that day, he reviewed the records, including the MRI reports from May of 2005 and November of 2005.143 He confirmed that the clinic visit on November 18, 2005, showed the employee reported she had prior low back pain in December of 2004, which had improved with conservative treatment, but her symptoms did not completely abate.144 He also confirmed the November 18, 2005, clinic report for the employee indicated the diagnosis was discogenic low back pain, which he identified as pain caused by the disc, secondary to herniated nucleus pulposus at L4-L5 and L5- S1.145 He testified that the clinic report showed no frank, classic radiculopathy, but did show she had symptoms of back pain going into her leg.146 The clinic report showed restricted range of motion in the spine in all planes, which Dr. James stated could be caused by pain and/or the disc injury, as well as facet pain or aging.147 He stated weight factors – being fat – were not a factor in the production of loss of motion.148

Dr. James testified the significant degenerative disc degeneration reported from the November 23, 2005, MRI was probably due to the work injury at Providence on December 27, 2004, as the May 6, 2005, MRI did not show any significant disc degeneration,149, 150 and at the employee’s young age, she should not have had significant disc degeneration.151 Furthermore, significant disc degeneration could not have occurred between the November 18, 2005, work injury at First 140 Id. 141 Id., pg. 52-53. 142 Id., pg. 6-8. 143 Id. 144 Id. 145 Id., pg. 8. 146 Id. 147 Id., pg. 8-10. 148 Id. 149 Id., pgs. 11-12. 150 Id, pg. 35. 151 Id., pg. 124.

Student and the November 23, 2005 MRI which showed the significant disc degeneration for the first time.152 Also, he noted the employee did not have back pain prior to her work injury at Providence.153 He also testified the central herniation at L4-L5 shown on the May 2005 MRI was from the injury at Providence, just extended.154 He testified although there was an extension of the disc herniation at L4-L5, it did not result in an increased PPI rating.155 Dr. James testified the injury at Providence was significantly more serious than the one at First Student, and the injury at Providence is the basis of her entire problem.156

Dr. James testified that it has to be recognized the employee did have an injury at First Student which produced significant impairment of functional capacity for a period of time, and there is documentation of some difference in L4-L5 between the May 2005 MRI and the November 2005 MRI’s.157 Dr. James noted the employee’s pain level was at a 2-3 level before her injury at First Student, and after a flare up due to the injury at First Student, the pain level settled back to the basic level it had been before her injury at First Student.158 Therefore, Dr. James stated the employee’s disc pathology is the consequence of her employment at Providence,159 and the work injury at First student represented a temporary aggravation of symptoms from her original injury.160 He also testified the work injury at First Student would not have happened if she had not been injured at Providence.161 Finally, Dr. James testified the work injury at First Student resolved after 3 to 4 months, and treatment or disability after that date would be due to the pre- existing condition.162 He testified his opinion differed from Dr. Yodlowski’s in that he believed the pre-existing condition was caused by the work injury at Providence, whereas Dr. Yodlowski believed the employee’s pre-existing condition was degenerative disc disease that was in the employee’s spine prior to her working at Providence.163 Dr. James testified that after the

152 Id., pgs.123-124. 153 Id., pgs. 29-30. 154 Id., pg. 12. 155 Id., pg., 30. 156 Id., pg. 76. 157 Id., pg. 31. 158 Id., pg. 29-31. 159 Id., pg. 30. 160 Id., pg. 31-32. 161 Id. 162 Id., pg. 34-35. 163 Id., pg 35-36.

24 BETHANN M. JACKSON v. PROVIDENCE HEALTH SYSTEM v. FIRST STUDENT SERVICES temporary aggravation caused by the November 2005 work injury resolved three to four months after the injury, the substantial cause of any ongoing disability or medical treatment was the 2004 work injury at Providence.164

Concerning the February 18, 2005 motor vehicle accident, Dr. James testified that when someone wears a seatbelt, they do not have lower back injuries.165 He stated the February 2005 auto accident was not a substantial factor in the employee’s PPI.166 Dr. James testified the physical exams performed by ANP Huffman after the work injury at Providence were not as detailed as those of ANP Wilson after the work injury at First Student.167

As discussed above, in his PPI report dated March 29, 2007, Dr. James assigned the employee a 16% whole person impairment,168 and apportioned this rating between the employers with a 75% contribution from the work at Providence and 25% from the employee’s work at First Student. 169 He reasoned that the L4-5 and L5-S1 disc pathologies were caused by the work injury at Providence on December 27, 2004, but that the injury at First Student on November 19, 2005 extended the protrusion at L4-5 based on the second MRI read by Dr. Cable.

Dr. James changed this apportionment at his December 19, 2007 deposition. He stated he realized it could not be apportioned.170 He concluded the employee’s work at Providence was and remains “a substantial factor” in bringing about the employee’s current symptoms, including the entire amount of PPI. He testified the employee’s work injury at First Student only temporarily aggravated the underlying disc condition for about three to four months, resolving by March 2006.171 Dr. James stated the November 18, 2005 injury could be eliminated as a substantial factor in producing a permanent aggravation of the employee’s symptomatology and functioning.172

164 Id., pg. 48. 165 Id., pg. 78. 166 Id., pg. 128. 167 Id., pg. 33. 168 Dr. James PPI rating, 3/13/07. 169 Id. 170 Dr. James Deposition, 12/19/07, pg. 115-116. 171 Id., pg. 125. 172 Id., pg. 126-127.

C. DEPOSITION TESTIMONY OF MARILYN YODLOWSKI, M.D. Marilyn Yodlowski, M.D., testified by deposition taken on October 31, 2007. Dr. Yodlowski graduated from Harvard Medical School.173 She completed a surgical postgraduate training program, then specialized in orthopedic surgery.174 She was chief resident in orthopedics at Massachusetts General Hospital.175 Dr. Yodlowski is board certified in orthopedic surgery.176 She is licensed to practice medicine in both Oregon and Alaska, but discontinued her Massachusetts medical license.177 She recently served as a speaker at the American Academy of Orthopedic Surgeons, 9th Annual Occupational, Orthopedics and Workers’ Compensation Course, where she also led a workshop on impairment ratings.178 After she moved to Oregon in 2001, she began doing independent medical evaluations,179 to have more time to devote to her family.180 She works for the company Impartial Medical Opinions. Dr. Yodlowski was board certified by the American Board of Independent Medical Examiners (“IME”), which is not recognized by the American Board of Medical Specialties.181 She has not treated a patient for a low back condition, nor has she had hospital privileges, since 2001.182

Dr. Yodlowski stated that the employee had degenerative disc disease prior to her employment injury at Providence. The events of December 27, 2004 only caused an acute onset of symptoms but did not increase her overall permanent impairment.183 Further, she states “the motor vehicle accident likely represented a new acute lumbosacral sprain/ strain superimposed upon her almost resolved work injury and the chronic underlying degenerative disease of the lumbosacral spine.”184 The accident “represented one of the instances when [she] had a symptomatic

173 Dr. Yodlowski’s Deposition, 10/31/07, pg. 8. 174 Id. 175 Id., pg. 9. 176 Id., pg. 10. 177 Id., pg. 9. 178 Id., pg. 10. 179 Id., pg. 11 180 Id., pg. 14. 181 Id., pg 15-16. 182 Id., pgs. 16-17. 183 Dr. Yodlowski’s 8/1/07 EME Report, pg. 8. 184 Id., at 9.

26 BETHANN M. JACKSON v. PROVIDENCE HEALTH SYSTEM v. FIRST STUDENT SERVICES exacerbation” but no permanent aggravation.185 The accident did extend the duration of time before she achieved medical stability to June 2005.186 Finally, Dr. Yodlowski stated the November 18, 2005 injury at First Student also represented a temporary aggravation of her pre- existing condition which resolved within three months and was the substantial cause of disability and need for treatment for those three months following the event.187

Based on her assessment of the employee’s disability using the DRE method, Dr. Yodlowski maintains the employee sustained no (zero percent) PPI from her work at Providence or the motor vehicle accident or First Student.188 Dr. Yodlowski explains in detail the basis of her disagreement with Dr. James as to his method (ROM) for determining PPI, as discussed above.189 Nevertheless, Dr. Yodlowski states:

I would like to comment that if [the employee] did fall into the category of having multiple levels of involvement, then I would agree with Dr. James’ impairment rating evaluation. However, as noted above, I do not believe that the multi-level degenerative disc changes, including the posterior central protrusions without nerve root compression, and in the absence of any clear radiculopathy, would categorize her as multilevel involvement to use the range of motion method.190

Dr. Yodlowski reaffirmed the positions taken in her EIME report at her deposition.

D. TESTIMONY OF REBECCA HAMM Rebecca Hamm was called by the employee and testified in person. Ms. Hamm said she is a casual friend of the employee. She was also the employee’s co-worker at Primary Care Associates (not a party to the claim) in the fall of 2006 and trained the employee during the MAS program. During the MAS program, Ms. Hamm testified she had adequate opportunity to observe the employee during work. She noticed nothing to indicate the employee was having any difficulty performing her job. Later however, when they worked together for two months working 60 hour weeks at Primary Care Associates, Ms. Hamm noticed the employee appeared

185 Id., at 8. 186 Id., at 8. 187 Id., at 11. 188 Id., at 14. 189 Id., at 12-13. 190 Id., at 14.

“OK” at the beginning of a shift, but her facial expressions indicated she was in pain by the end of the shift.

E. DEPOSITION TESTIMONY OF BRIAN JOHNSON Brian Johnson was called by the employee and testified by deposition because he was scheduled for military deployment overseas at the time of the hearing. Mr. Johnson is the employee’s boyfriend. He has known the employee since 2001 when they met through volunteer work with the Alaska Medical Support Team and took martial arts classes together.

Mr. Johnson authenticated photographs (also introduced at hearing by the employee) demonstrating her pre-injury ability to lift, participation in martial arts events, and her comparatively slim physique.

Prior to the injury at Providence, he described the employee as a “fireball . . .she wanted to do a lot of things, and none of it was sedentary.” As an example, Mr. Johnson testified the employee enjoyed go-carting, bicycling, roller-blading, skating, cross-country and down-hill skiing and even canoeing despite her dislike of the water. Mr. Johnson testified the employee never complained of back pain while participating in these activities. Later in the deposition, Mr. Johnson confirmed that the employee previously used her bike as a primary form of transportation.

In late 2004, their friendship evolved. It was during the time when the employee worked for Providence that they moved into the same residence. After the employee injured her back, Mr. Johnson testified she was unable to perform even simple domestic chores such as grocery shopping, vacuuming, and cooking. He testified she was able to continue working but was exhausted, in pain, and had difficulty sleeping.

Mr. Johnson testified about the employee’s motor vehicle accident in February 2005. Although he was not a passenger in the vehicle, he was present immediately thereafter at the emergency room where his daughter (a passenger) and the employee and her two children were evaluated for their injuries. Although hearsay, Mr. Johnson testified that he heard the employee tell the

28 BETHANN M. JACKSON v. PROVIDENCE HEALTH SYSTEM v. FIRST STUDENT SERVICES medical personnel she had a pre-existing low back condition but that the accident caused her neck pain which extended into her shoulders. After the accident, the “stiffness” in her neck and upper back lasted for “a week, maybe two” before it went away.

At the time the employee was terminated from her employment, Mr. Johnson testified her low back appeared in very poor condition. He attributed it to the employee’s inability to comply with the physical therapy program because of scheduling conflicts with her work at Providence. After she was terminated, the employee seemed to slowly improve. However, her inability to work caused financial hardship on the employee’s family. Mr. Johnson testified he supplemented income the employee received from unemployment during this time. By the time the employee went to work for First Student, Mr. Johnson testified the employee was able to perform the work, but after three or four days, her back would begin to hurt in the same area which she had injured at Providence.

As to her physical condition, Mr. Johnson testified that when the employee’s low back hurt to the extent she could not work, she would also reported radiating leg pain. “It wasn’t any specific incident. It was a lot of incidents when she would overwork her back.” These symptoms, Mr. Johnson testified, existed prior to her injury at First Student. However, after the First Student injury, Mr. Johnson said her symptoms “dramatically” increased. “It was like having to start the Providence physical therapy all over again. Having pain that’s almost unbearable to start out the day, and then ending the day with a -- at the same level or worse.”

Following the Student First injury, the employee was assigned to the dispatch center. Also, for the first time, the employee was seen by a physician at Alaska Spine Institute. Although she still has problems, Mr. Johnson testified that her symptoms seem more minimal; which he attributes to her far less active lifestyle. He also attributes her weight gain to her inability to participate in activities as she did prior to the Providence injury.

After the Providence injury she could not run or mountain bike any longer although she can now ride an ergometric bicycle for about ¾ of a mile. Mr. Johnson testified that her pain and symptoms appeared to be at the same level as before the Student First injury, but that her ability

29 BETHANN M. JACKSON v. PROVIDENCE HEALTH SYSTEM v. FIRST STUDENT SERVICES to do the same things has not returned to the same level. Mr. Johnson confirmed the employee’s testimony that by March 2006, her symptoms returned to the level she recalled them being after her injury with Providence.

Mr. Johnson also testified about his understanding of the injuries the employee incurred at Providence and First Student. In most respects, his understanding reflects the employee’s testimony because he was not an eye witness to the events. Mr. Johnson testified that he was not aware of the second incident at Providence, that is, the collapse of a wheelchair, and the employee’s back pain attributed to it.

F. ARGUMENTS OF THE EMPLOYEE The employee argued that prior to her work injury at Providence, she had no complaints of back pain, nor had she sought any treatment for any back related condition.191 After her injury at Providence, the employee suffered from low back pain which continued until she had her second injury at First Student on November 18, 2005.192 Thereafter, the employee has continued to have and be treated for low back pain.193

The employee argues according to the testimony of her treating physician, Dr. James, the December 27, 2004, work injury at Providence is a substantial factor in causing her low back condition and remains a substantial factor for her current condition, continuing symptoms, need for treatment through the present, and PPI rating.194 Further, Dr. James stated the employee’s condition was not medically stable until the Fall of 2005.195

The employee argued the employee’s doctors have concluded her injuries contribute to her low back condition, symptoms and need for continuing treatment, which is sufficient to establish causation and the necessity of treatment, and further to raise the presumption of compensability.196 Further, she argues once the presumption of compensability is established,

191 Employee’s Hearing Brief, pg. 5. 192 Id., pgs. 6-7. 193 Id., pg 9. 194 Id., pg. 10. 195 Id. 196 Employee’s Hearing Brief, 12/31/07, pg. 14-15.

30 BETHANN M. JACKSON v. PROVIDENCE HEALTH SYSTEM v. FIRST STUDENT SERVICES she is entitled to the presumption of continuing compensability.197 Providence and First Student, relying on the EME physician Dr. Yodlowski’s opinion, have failed to rebut the presumption of continuing compensability, since that opinion did not rule out work related causes, but simply pointed to other possible causes for the disability.198 The employee requested medical benefits for all periods pursuant to the treating doctor’s recommendations, temporary disability benefits, PPI benefits, interest, and attorney’s fees and costs.199

During closing arguments, the employee claimed Providence has raised several red herrings, including the wheelchair incident and the motor vehicle accident, which the doctors have stated played no role in the employee’s injuries, and the charge of fraud. The employee argued when she filed the small claims action against Providence in an attempt to have her medical expenses due to her work related injury reimbursed, Providence should have told the employee to file a WCC, not charge her for attorney’s fees. The employee also contended her WCC was timely filed in January of 2007, as she only learned the nature of her disability in November of 2005.

G. ARGUMENTS OF FIRST STUDENT First Student argues it has successfully rebutted the presumption that First Student is the substantial cause or even a substantial factor in the employee’s current condition and need for medical treatment. First Student relies on the testimony of Dr. James and Dr. Yodlowski, both of whom stated the November 18, 2005 work injury at First Student was not a substantial factor in producing a permanent aggravation of the employee’s symptomatology and functioning.200 First Student notes the Board has long recognized a work injury may either temporarily or permanently aggravate a preexisting condition,201 and both Dr. James and Dr. Yodlowski, as well as the employee, agree the November 18, 2005 work injury only temporarily aggravated the employee’s pre-existing condition.

197 Id., pg. 15. 198 Id., pgs. 15-16. 199 Id., pgs. 16-19. 200 First Student’s Hearing Brief, 1/11/08, pg. 16. 201 Id.

First Student also contends Providence is responsible for the employee’s PPI, based on Dr. James testimony the work injury at Providence was a substantial factor in the PPI rating and his testimony he would have given her the same PPI rating had her rated her prior to the November 18, 2005 work injury.202

First Student next argued any medical bills or associated transportation costs is the responsibility of Providence, as according to the testimony of Dr. James, the work injury at First Student had resolved by three to four months after the injury, which would have been about the middle of March, 2006.203 First Student requested reimbursement from Providence for any medical expenses paid after March of 2006.204 First Student also stated no penalty should be assessed in this case, as no claim has been filed, nor was it asserted at the prehearing conference.205 Finally, First Student stated Providence should be responsible for the employee’s attorney’s fees and costs.206

H. ARGUMENTS OF PROVIDENCE Providence first argued the employee’s claim is barred by AS 23.30.100 for failure to give notice of the injury in the wheelchair incident that caused her to seek medical care.207 It argued that even if the Board excuses the late notice, then the provisions of AS 23.30.120(b) do not provide for a presumption of compensability.208 Providence argued that the requirements of notice in AS 23.30.100(a) and (b) should be read in conjunction with the prohibitions in AS 23.30.250(b) to deny the employee from profiting from her false and misleading Notice of Injury and the employee’s claim should be denied and dismissed.209

Providence argued First Student is unable to rebut the presumption the injury at First Student is the substantial factor of the disability that happened thereafter, and that “but for” the injury of

202 First Student’s Hearing Brief, 1/11/08, pg 19. 203 Id., pgs. 19- 20. 204 Id., pg. 20. 205 Id. 206 Id. 207 Providence’s Hearing Brief, 1/3/08, pg. 3. 208 Id., pg. 4. 209 Id., pgs. 3-4.

November 18, 2005, the employee would not have suffered disability at this time, or in this way, or to this degree.210 Providence further argued First Student, in order to overcome the presumption, must present affirmative evidence the PPI is not related to work at First Student or eliminate all reasonable possibilities that the PPI is related to work at First Student. 211 Providence claimed since ANP Wilson and Dr. James both at various times attached permanent consequences to the injury at First Student, their testimony cannot rebut the presumption that First Student is the cause of the employee’s current condition. Providence also claimed First Student’s reliance on Dr. Yodlowski’s testimony to rebut the presumption is misplaced, as Dr. Yodlowski used the wrong legal standard – that of “the major contributing factor” rather than “ the substantial cause” - in determining the injury at First Student was not the major contributing factor for the employee’s current condition.212

Concerning application of the last injurious exposure rule, Providence argued First Student is unable to come forward with substantial evidence that the injury at First Student did not aggravate, accelerate, or combine with the preexisting condition to bring about the employee’s disability.213 Providence stated ANP Wilson and Dr. James at the Alaska Spine Institute both categorized the First Student injury as a “permanent aggravation.”214 Providence argued only Dr. Yodlowski properly applied the AMA Guides to the employee’s condition for the PPI rating.

Concerning the December 27, 2004 work injury, Providence argued the employee recovered rapidly and was essentially pain free by February 10, 2005. Providence argued the employee’s subsequent back problems until May 24, 2005, when she was pain-free, were due to the motor vehicle accident, when Providence claimed she injured her lower back.215

210 Id., pg. 15. 211 Id. 212 Id., pg. 15. 213 Id., pg. 17. 214 Id. 215 Id., pg. 18.

Providence also stated the employee’s claim for benefits after the February 18, 2005 motor vehicle accident are barred under AS 23.30.015(h), as the employee settled and was paid for aggravation of the back injury without the approval of Providence.216

Providence stated the injury at First Student was worse than the one at Providence, based on her pain level, symptoms, and period of recovery.217 Providence argued the symptom of buttocks pain arose only from the work incidents – Providence claimed the employee suffered two work injuries at First Student, one on October 19, 2005 and one on November 18, 2005.218

Providence argued the employee’s claims for disability compensation are barred under AS 23.30.105 as she filed her WCC on January 8, 2007, when she knew in December 2004 she was disabled due to a work injury.219

Finally, Providence appealed the Prehearing Officer’s decision denying Providence’s request for discovery from ANP Wilson and Dr. James concerning information as required for experts, such as curricula vitae, lists of publications authored, and lists of complaints, grievances, claims or similar actions, which may have been filed against the two health care professionals.220 Providence had also requested a list of any disciplinary actions or limitations on practice or other adverse action taken by any professional occupational licensing agency, state or federal government agency, association or insurance company with respect to the two professionals.221 In addition, Providence requested letters, emails and other correspondence between the employee and Alaska Spine Institute, as well as similar documents at Alaska Spine Institute concerning the employee. Providence argued the issue of whether claimants must make disclosures regarding their treating physicians when they have used them as experts comes up frequently, and Providence believes the Prehearing Officer’s decision is not in accord with the Appeals Commission decision in McGahuey v. Whitestone Logging.222, 223

216 Id. 217 Id., pg. 19. 218 Id. 219 Id. 220 Id., pgs. 19-20. 221 Providence’s Hearing Brief, 1/3/08, Exhibit 5.

During closing arguments, in addition to restating some of the arguments in its brief, Providence stated the employee’s PPI rating should be 0% as there was no testimony concerning limitations on her activities of daily living (“ADL’s”).224 Providence also argued the employee’s failure to report the wheelchair incident, her claim she did not know the results of the May 2005 MRI for months, when she knew the results at the end of June, and her claim to have low back pain when a number of medical records show that she was pain free, damage her credibility.

FINDINGS OF FACT AND CONCLUSIONS OF LAW

I. IS THE EMPLOYEE’S CLAIM AGAINST PROVIDENCE BARRED BY OPERATION OF AS 23.30.100 (NOTICE), AS 23.30.250 (FRAUD) AS 23.30.015(H) (RE: THIRD PARTY SETTLEMENTS WITHOUT WRITTEN APPROVAL), AND/OR AS 23.30.105 (STATUTE OF LIMITATIONS)?

We now turn our attention to the defenses raised by Providence in support of its argument the employee’s claim against it is barred by operation of AS 23.30.100, AS 23.30.105, AS 23.30.250 and/or AS 23.30.015 of the Act. A. AS 23.30.100 AS 23.30.100 provides: Notice of injury or death.

(a) Notice of an injury or death in respect to which compensation is payable under this chapter shall be given within 30 days after the date of such injury or death to the board and to the employer.

222 McGahuey v. Whitestone Logging, Decision No. 54, dated August 28, 2007. Providence also relies on Shapardon v. West Beach Estates, 172 F.R.D. 415 (D. HI 1997). 223 The Board finds the issue of the appeal of the Prehearing Officer’s discovery order is not an issue for this hearing pursuant to 8 AAC 45.065. Providence was directed to appeal the discovery order within 10 days of the 9/26/07 Prehearing conference, which Providence failed to do. In addition, responses to some of the discovery questions as to Dr. James were answered in Dr. James 12/19/07 deposition. 224 However, the Board finds there was abundant testimony concerning limitations on the employee’s ADL’s per Table 1-3, pgs. 6-7, of the AMA Guides, which physicians may use in addition to Table 1-2 on page 4.

(b) The notice must be in writing, contain the name and address of the employee, a statement of the time, place, nature, and cause of the injury or death, and authority to release records of medical treatment for the injury or death, and be signed by the employee or by a person on behalf of the employee, or, in case of death, by a person claiming to be entitled to compensation for the death or by a person on behalf of that person.

(c) Notice shall be given to the board by delivering it or sending it by mail addressed to the board's office, and to the employer by delivering it to the employer or by sending it by mail addressed to the employer at the employer's last known place of business. If the employer is a partnership, the notice may be given to a partner, or if a corporation, the notice may be given to an agent or officer upon whom legal process may be served or who is in charge of the business in the place where the injury occurred. The statutory exceptions for the 30-day notice requirement are set forth in AS 23.30.100(d) which provides: (d) Failure to give notice does not bar a claim under this chapter (1) if the employer, an agent of the employer in charge of the business in the place where the injury occurred, or the carrier had knowledge of the injury or death and the board determines that the employer or carrier has not been prejudiced by failure to give notice; (2) if the board excuses the failure on the ground that for some satisfactory reason notice could not be given; (3) unless objection to the failure is raised before the board at the first hearing of a claim for compensation in respect to the injury or death. In Cogger v. Anchor House,225 the Alaska Supreme Court held: An employee must provide formal written notice to his or her employer within thirty days of an injury in order to be eligible for workers' compensation. AS 23.30.100. For reasons of fairness and based on the general excuse in AS 23.30.100(d)(2), this court has read a "reasonableness" standard, analogous to the "discovery rule" for statutes of limitations, into the statute. Alaska State House. Auth. v. Sullivan, 518 P.2d 759, 761 (Alaska 1974). Under this standard, the thirty-day period begins when "by reasonable care and diligence it is discoverable and apparent that a compensable injury has been sustained." Id. at 761 (quoting 3 Arthur Larson, Workmen's Compensation, Sec. 78.41, at 60 (1971)). . . . Under Sullivan, the thirty- day period begins to run when the worker could reasonably discover an injury's compensability. 518 P.2d at 761. The exact date when an employee could reasonably discover compensability is often difficult to determine, and missing the short thirty-day limitation period bars a claim absolutely. For reasons of clarity and fairness, we hold that the thirty-day period can begin no earlier than when a

225 936 P.2d 157, 160 (Alaska 1997).

compensable event first occurs. However, it is not necessary that a claimant fully diagnose his or her injury for the thirty-day period to begin. (Footnote omitted). 226

Providence argues that, while either AS 23.30.100 (failure to notify) or AS 23.30.250 (fraud) would be sufficient to bar her claim independent of the other, when combined they are even more compelling. First we will consider these defenses in isolation.

When an employee has not notified the employer of an injury (in this case the wheelchair incident) in accordance with AS 23.30.100, the employee’s claim may be barred unless the provisions of AS 23.30.100(d) have been met.

The presumption applies to the timeliness of notice.227 Under AS 23.30.105, for notice to be timely, it must be given within 30 days of the injury. A claim will not be barred for failure to give timely notice, however, if the employer was aware of the injury and the Board determines the employer was not prejudiced by the failure to give such notice.228

We find the employee has raised the presumption of timely notice for her injury through her timely notice of her back injury on the same day on which the injury occurred, that is, January 27, 2004. It is true she only reported to the manager the first incident when she was assisting the obese patient on the day of the injury. However, the employee testified at hearing she considered the incident with the obese patient to be when the injury occurred. She stated, “[T]he injury was rolling the patient. The wheelchair incident…[was] my back saying you’ve pushed beyond what I can do.” We find the employee credible.229 We find her credible based on her overall demeanor during her testimony on direct as well as cross examination. Although we noted the few discrepancies in her testimony that were brought out particularly on cross examination, we did not find these discrepancies were significant so as to damage her credibility.

226 Id. 227 AS 23.30.120(a)(2). See also, McGahuey v. Whitestone Logging, Decision No. 54, August 28, 2006. 228 AS 23.30.100(d)(1). 229 AS 23.30.122.

We find the employee gave timely notice of her back injury, reporting the incident she regarded as being the cause of her injury. We find her failure to report the specific incident with the wheelchair to the manager does not rebut the presumption. Even if we did find the failure to report the wheelchair incident rebutted the presumption of compensability, we find the employee has proven by a preponderance of the evidence that her notice was timely.

In addition, we conclude the employee’s failure to provide notice of the wheelchair incident does not bar her claim for the following reason. AS 23.30.100(d)(1) states the employer must have been aware of the injury, even though there was no notice in writing within 30 days, and that the employer or carrier has not been prejudiced by the failure to give notice.

Providence has not proved to our satisfaction it was prejudiced by the delay. We find the employee did notify her supervisor of the earlier work injury (turning the heavy patient in bed) the same day, albeit after the second injury happened, and the employer immediately had the employee evaluated by a medical professional of its choice. One reason for requiring timely written notice is that timely notice allows the “employer to provide immediate medical diagnosis and treatment to minimize the seriousness of the injury.”230 Here, we find that the employee reported her back injury on the same day it occurred, and the employer was able to provide immediate medical diagnosis and treatment to minimize the seriousness of the injury.

The second reason for the requirement for timely notice is timely notice “facilitates the earliest possible investigation of the facts surrounding the injury.”231 To prove prejudice on this second basis, the employer would have to prove that it was “hampered in making its investigation and preparing its case.”232 Prejudice in this category most frequently occurs because the employer learns of an injury too late to determine whether the injury is work-related or not.233 We find that the significant work injury suffered by the employee occurred during the first incident when she rolled the obese patient in bed. Under the facts of the instant case, we find the employee’s

230 Tinker v. Veco, Inc. 913 P.2d 488, 492 (Alaska 1996). 231 Id. 232 A. Larson, Workmen's Compensation s 126.04, at 15-16 (2000); accord, Morrison-Knudsen Co. v. Vereen, 414 P.2d 536, 537 (Alaska 1966). 233 Id., at 16-17.

38 BETHANN M. JACKSON v. PROVIDENCE HEALTH SYSTEM v. FIRST STUDENT SERVICES notification to the employer of this first incident was sufficient to satisfy this second purpose of the statute, i.e., the employer was timely notified that the employee had suffered an injury to her back and had an opportunity to investigate whether or not that injury was work-related. Further, we find Providence’s claim it was prejudiced in its ability to investigate the wheelchair incident because it exposed the hospital to liability from the patient is irrelevant to application of AS 23.30.100. AS 23.30.100 concerns itself only with the employee’s ability to prosecute her claim, and the employer’s ability to defend its claim, not a third party’s efforts to collect damages in a tort action.

In Kolkman v. Greens Creek Mining Co.,234 the Alaska Supreme Court held that even if the employee is interpreted as having failed to give timely, formal written notice, that the employee’s claim would not be barred by AS 23.30.100, because the employer had knowledge of the general, cumulative injury and was not prejudiced by the delay. In Kolkman the Court disapproved the requirement which sprang from State v. Moore,235 that the employer must have knowledge of the work-relatedness of the injury. The Court in Kolkman held that the statute should be read literally to require only that the employer must have knowledge of the injury. In Tinker v. VECO, Inc.,236 the Court clarified the employee must show the employer had actual knowledge, and suffered no prejudice which would thwart the two purposes of AS 23.30.100: early diagnosis and treatment, and early investigation. In the instant case, the employee reported her general back problems to the employer when she spoke to her manager. We find the employer had actual notice of the employee’s back injury nearly immediately, and had ample opportunity to investigate or secure treatment for the employee. Accordingly, under the Courts’ rationale in Kolkman, we also find the employee’s report of injury is timely under AS 23.30.100.

B. AS 23.30.250, or Combination of AS 23.30.250 and AS 23.30.100 AS 23.30.250 provides:

Penalties for fraudulent or misleading acts; damages in civil actions.

234 936 P.2d 150, 156 (Alaska 1997). 235 706 P.2d 311 (Alaska 1985). 236 913 P2d 488, 492, 493 (Alaska 1996).

(a) A person who (1) knowingly makes a false or misleading statement, representation, or submission related to a benefit under this chapter; (2) knowingly assists, abets, solicits, or conspires in making a false or misleading submission affecting the payment, coverage, or other benefit under this chapter; (3) knowingly misclassifies employees or engages in deceptive leasing practices for the purpose of evading full payment of workers' compensation insurance premiums; or (4) employs or contracts with a person or firm to coerce or encourage an individual to file a fraudulent compensation claim is civilly liable to a person adversely affected by the conduct, is guilty of theft by deception as defined in AS 11.46.80 , and may be punished as provided by AS 11.46.120 - 11.46.150.

(b) If the board, after a hearing, finds that a person has obtained compensation, medical treatment, or another benefit provided under this chapter, or that a provider has received a payment, by knowingly making a false or misleading statement or representation for the purpose of obtaining that benefit, the board shall order that person to make full reimbursement of the cost of all benefits obtained. Upon entry of an order authorized under this subsection, the board shall also order that person to pay all reasonable costs and attorney fees incurred by the employer and the employer's carrier in obtaining an order under this section and in defending any claim made for benefits under this chapter. If a person fails to comply with an order of the board requiring reimbursement of compensation and payment of costs and attorney fees, the employer may declare the person in default and proceed to collect any sum due as provided under AS 23.30.170(b) and (c).

(c) To the extent allowed by law, in a civil action under (a) of this section, an award of damages by a court or jury may include compensatory damages and an award of three times the amount of damages sustained by the person, subject to AS 09.17. Attorney fees may be awarded to a prevailing party as allowed by law.

We next consider Providence’s argument that because the employee intentionally lied, by omission, her claim should be barred by AS 23.30.250 alone, or in combination with AS 23.30.100. As stated, we conclude the provisions of AS 23.30.100(d) are not satisfied to bar her claim. We find it is unnecessary, therefore, to consider AS 23.30.250 in combination with AS 23.30.100.

Providence argues that it was the wheelchair incident that was the actual injury that caused the employee to seek medical care and that the employee intentionally misled Providence about the time, place, nature and cause of injury.237 Providence also argues the “requirement of prompt notice is not only to provide the injured worker with timely diagnosis and treatment, but also to allow employer with the earliest possible investigation of the facts surrounding the injury.”238 Providence further argues it was prejudiced by the late report of the wheelchair incident, as described in the affidavit of Anne Pence.239 In her November 15, 2007 affidavit, Anne Pence stated Providence was prejudiced as it was not notified of the possible malfunction in the wheelchair so that it could repair it, stop its use, and potentially prevent someone else from getting hurt.240 She also stated Providence was not able to determine the identity of the patient that was “dropped,” and whether that patient had been hurt.241 Finally, Anne Pence stated Providence was prejudiced as the wheelchair incident might have resulted in liability to Providence, and prompt investigation would have been the only way to know what actually happened to allow Providence to preserve that information for the patient and Providence.242 AS 23.30.250(b) states that if the Board finds the deception, “a false or misleading statement or representation” was made for the purpose of “obtaining a benefit” the Board shall order the employee to repay any benefits received. We fail to see, must less find, how the employee’s omission amounts to a misleading statement or representation made for the purpose of obtaining benefits. If she had advised the employer of the second incident, it would not have barred her claim for benefits. To the contrary, it would have provided a secondary basis for the recovery of benefits. In addition, we found the employee credible when questioned about the incident at the hearing. We observed her demeanor when she was questioned about the wheelchair incident and her omission at the hearing, and we found her more professionally embarrassed by her failure to protect her patient than anything else. Consequently, whatever motivation the employee did have for not disclosing the wheelchair incident is irrelevant, as long as that motive was not for the purpose of obtaining a benefit, which we find that it is not. We conclude AS 23.30.250, under the facts presented, does not act as a bar to the employee’s claim.

237 Providence Hearing Brief, 1/3/08, pg. 3. 238 Id. 239 Id. 240 Affidavit of Anne Pence, 11/15/07. 241 Id. 242 Id.

C. AS 23.30.015

AS 23.30.015 provides, in pertinent part:

Compensation where third persons are liable. (a) If on account of disability or death for which compensation is payable under this chapter, the person entitled to the compensation believes that a third person other than the employer or a fellow employee is liable for damages, the person need not elect whether to receive compensation or to recover damages from the third person. … (f) Even if an employee, the employee's representative, or the employer brings an action or settles a claim against the third person, the employer shall pay the benefits and compensation required by this chapter.

(h) If compromise with a third person is made by the person entitled to compensation or the representative of that person of an amount less than the compensation to which the person or representative would be entitled, the employer is liable for compensation stated in (f) of this section only if the compromise is made with the employer's written approval.

Next we consider Providence’s argument the employee’s claim should be barred by operation of AS 23.30.015(f) because she settled her motor vehicle accident claim with the third party driver who rear ended her vehicle in February 2005.

First, we find the motor vehicle accident, which involved only non-work related travel, has no connection to the work injury for which the employee is claiming benefits. Therefore, we conclude the employee’s settlement with the liable third party tortfeasor cannot, by operation of AS 23.30.015, bar her claim. Nevertheless, the employee’s settlement from the third party tortfeasor, the settlement of $2,300.00, might be cause for an offset.

Dr. James, the employee’s treating physician, opined the automobile accident did not cause the permanent impairment he assessed. Similarly, Dr. Yodlowski, the EME physician, testified the accident may have temporary caused a spike in her low back symptoms and/or delayed her

42 BETHANN M. JACKSON v. PROVIDENCE HEALTH SYSTEM v. FIRST STUDENT SERVICES recovery from the effects of the work injury, perhaps until June, 2005, but did not cause her underlying condition which she testified pre-existed the work injury. The employee settled her claim the first week of July 2005 for all damages (property and personal, such as time loss from work) arising from the vehicular accident in February 2005. By the preponderance of the available evidence, we find the present benefits claimed by the employee are unrelated to the motor vehicle accident.

D. AS 23.30.105

AS 23.30.105 provides, in relevant part: Time for filing of claims. (a) The right to compensation for disability under this chapter is barred unless a claim for it is filed within two years after the employee has knowledge of the nature of the employee's disability and its relation to the employment and after disablement. However, the maximum time for filing the claim in any event other than arising out of an occupational disease shall be four years from the date of injury, and the right to compensation for death is barred unless a claim therefor is filed within one year after the death, except that if payment of compensation has been made without an award on account of the injury or death, a claim may be filed within two years after the date of the last payment of benefits under AS 23.30.041, 23.30.180, 23.30.185, 23.30.190, 23.30.200, or 23.30.215. It is additionally provided that, in the case of latent defects pertinent to and causing compensable disability, the injured employee has full right to claim as shall be determined by the board, time limitations notwithstanding. (b) Failure to file a claim within the period prescribed in (a) of this section is not a bar to compensation unless objection to the failure is made at the first hearing of the claim in which all parties in interest are given reasonable notice and opportunity to be heard. ….

Finally, we consider whether AS 23.30.105 bars the employee’s claim for benefits as against Providence. AS 23.30.105 provides that a claim must be filed within two years of knowledge of the “nature of the employee’s disability” or be barred. We conclude the claim is not barred for the following reasons.

The two year limitations period under AS 23.30.105 is tolled during the time “payment of compensation is made without an award.” Specifically, a “claim may be filed within two years after the date of the last payment of benefits under AS 23.30.041, AS 23.30.180, AS 23.30.185, AS 23.30.190, AS 23.30.200, or AS 23.30.215.” In this claim, the employer’s representative (Ann Pence, Providence’s workers’ compensation manager) first affied she had paid AS 23.30.200 (TPD) benefits, then later recanted.

As stated before, there is no compensation report and Ms. Pence did not testify. The employee did, however, testify she was unable to fully participate in physical therapy given the demands of her work. Although this is not direct evidence TPD was not paid, the employee’s statement does lend some credence to the fact she was not fully compensated for her partial disability. Nevertheless, in the absence of direct and credible proof to the contrary, we find the last payment of TPD benefits probably occurred at about the time the employee was terminated from her work in late February 2006. Therefore, we conclude the employee’s claim is not barred because she had until late February 2008 to file a claim.

Also, as noted above, AS 23.30.105 states that a claim must be filed within two years after the employee has knowledge of the nature of the employee’s disability and its relation to the employment and after disablement. We find that the employee did not have knowledge of the nature of her disability until it was explained to her by ANP Wilson at Alaska Spine Institute subsequent to her second injury and second MRI in November of 2005. Therefore, we find the employee had until November of 2007 to file a claim and her January 2007 claim was timely filed.

Alternatively, AS 23.30.105 also provides that if recovery in a lawsuit for damages in relation to a work injury is unsuccessful “on the ground that the person was an employee and that the defendant is the employer . . . and that the employer has secured compensation to the employee . . . the limitation of time . . . begins to run only from the date of termination of the suit.” In this case, the employee brought a small claim action against the employer. It was dismissed for lack of jurisdiction in May 2006. Therefore, in the alternative, we conclude the

44 BETHANN M. JACKSON v. PROVIDENCE HEALTH SYSTEM v. FIRST STUDENT SERVICES employee’s claim is not barred by AS 23.30.105 because she had at least until May 2008 for file her claim.

In summary, we conclude there is no bar to the employee’s claim for compensation against Providence pursuant to AS 23.30.100, AS 23.30.250, AS 23.30.015 or AS 23.30.105, of the Act.

II. LIABILITY UNDER THE LAST INJURIOUS EXPOSURE RULE

Providence has acknowledged the employee suffered a work injury on December 27, 2004. Although Providence argued the employee’s claim was barred for the reasons discussed above, we have found that the employee’s claim against Providence is not barred. First Student accepted the employee’s claim for her November 18, 2005 work injury at First Student until the time the employee reached medical stability at the end of March 2006. The disputed benefits under the last injurious exposure rule thus are for the employee’s PPI and current disability and ongoing benefits. The following discussion concerning the last injurious exposure concerns only these disputed benefits.

This case must be analyzed under the last injurious exposure rule adopted by the Alaska Supreme Court in Ketchikan Gateway Borough v. Saling, 604 P.2d 590 (Alaska 1979). The rule applies when employment with successive employers may contribute to an employee's disability. 243 This rule, combined with the presumption of compensability afforded by AS 23.30.120(a), "imposes full liability on the employer at the time of the most recent injury that bears a causal relation to the disability."244 In Peek v. SKW/Clinton, 855 P.2d 415, 416 (Alaska 1993), the Court stated: [T]wo determinations . . . must be made under this rule: "(1) whether employment with the subsequent employer 'aggravated, accelerated, or combined with' a pre- existing condition; and, if so, (2) whether the aggravation, acceleration or combination was a 'legal cause' of the disability, i.e., 'a substantial factor in bringing about the harm", (quoting Saling, 604 P.2d at 597, 598). An aggravation, acceleration or combination is a substantial factor in the disability if it is shown that (1) "but for" the subsequent employment the disability would not have occurred, and (2) the

243 Veco, Inc. v. Wolfer, 693 P.2d 865, 868, n. 1, (Alaska 1985). 244 Saling, 604 P.2d at 595, citing 4 A. Larson, The Law of Worker's Compensation, § 95.12 (1979).

45 BETHANN M. JACKSON v. PROVIDENCE HEALTH SYSTEM v. FIRST STUDENT SERVICES subsequent employment was so important in bringing about the disability that a reasonable person would regard it as a cause and attach responsibility to it.245 The Court expressly adopted the "but for" test in a last injurious exposure rule context in Fairbanks North Star Borough v. Rogers & Babler:246 The question of whether the employment aggravated or accelerated a pre-existing disease or injury is one of fact to be determined by the Board and it is not the function of the court to reweigh the evidence or choose between competing inferences." Peek 855 P.2d at 418. "As we pointed out in Saling, under the ‘last injurious exposure' rule, an employee need not show that employment with the last employer was the legal cause of disability, only a legal cause of the disability.247

In our analysis, we must first apply the statutory presumption of compensability. AS 23.30.120(a) provides in pertinent part: In a proceeding for the enforcement of a claim for compensation under this chapter it is presumed, in the absence of substantial evidence to the contrary, the (1) the claim comes within the provisions of this chapter. . . .248

The evidence necessary to raise the presumption of compensability varies depending on the type of claim. "[I]n claims based on highly technical medical considerations, medical evidence is often necessary in order to make that connection."249 In this case, the employee filed a claim against First Student, the most recent employer with possible liability for the disputed benefits, as well as a claim against Providence. We find the testimony of the employee and the opinions of her treating physician, Dr. James, concerning the aggravation of the employee’s pre-existing injury by her November 18, 2005, work injury at First Student, is sufficient to raise the presumption of compensability for the disputed benefits.

Once the presumption attaches, substantial evidence must be produced showing the disability is not work-related.250 Substantial evidence is such relevant evidence as a reasonable mind would accept in light of all the evidence to support a conclusion.251 There are two methods of overcoming the

245 See State v. Abbott, 498 P.2d 712, 727 (Alaska 1971). 246 Fairbanks North Star Borough v. Rogers & Babler, 757 P.2d 528, 533 (Alaska 1987). 247 Id. at 419, citing Saling, 604 P.2d at 598. 248 AS 23.30.120(a). 249 Burgess Construction Co. v. Smallwood, 623 P.2d 316 (Alaska 1981). 250 Smallwood, 623 P.2d at 316. 251 Kessick v. Alyeska Pipeline Serv. Co., 617 P.2d 755, 757 (Alaska 1980).

46 BETHANN M. JACKSON v. PROVIDENCE HEALTH SYSTEM v. FIRST STUDENT SERVICES presumption of compensability: (1) presenting affirmative evidence showing that the employee does not suffer work-related injury or disability; or (2) eliminating all reasonable possibilities that the injury is work-related.252 The same standards used to determine whether medical evidence is necessary to establish the preliminary link apply to determine whether medical evidence is necessary to overcome the presumption.253 "Since the presumption shifts only the burden of production and not the burden of persuasion, the evidence tending to rebut the presumption should be examined by itself."254

First Student argues the deposition testimony and the medical reports of Dr. James, and the medical reports of the employee’s other health care providers, as well as the testimony of the employee and her lay witnesses, rebut the presumption of compensability for the disputed benefits as to First Student. Dr. James testified the work injury at First Student resulted in only a temporary exacerbation of the employee’s preexisting back problems which were the result of the work injury at Providence. First Student also argues the deposition testimony and medical reports of Providence’s own EME physician, Dr. Yodlowski, show the work injury at First Student resulted in only a temporary exacerbation of the employee’s preexisting condition. We find First Student has presented sufficient evidence to rebut the presumption that the work injury at First Student is the substantial cause of the employee’s current condition.

The Board in Iversen v. Terrasond, D&O No. 07-350 dated November 19, 2007 discussed “the substantial cause”: [W]e will interpret “the substantial cause” of AS 23.30.10 in light of the long line of Alaska Supreme Court cases interpreting “substantial” to mean a quantum of evidence a reasonable person could believe sufficient to assign responsibility for causation.

If an employer produces substantial evidence the disability is not work-related, the presumption drops out, and the employee, or here, the other employer as well, must prove all elements of the

252 DeYonge v. NANA/Marriott, 1 P.3d 90, 96 (Alaska 2000); Grainger v. Alaska Workers' Compensation Board, 805 P.2d 976, 977 (Alaska 1991). 253 Wolfer, 693 P.2d at 871. 254 Id. at 869.

47 BETHANN M. JACKSON v. PROVIDENCE HEALTH SYSTEM v. FIRST STUDENT SERVICES case by a preponderance of the evidence.255 "Where one has the burden of proving asserted facts by a preponderance of the evidence, he must induce a belief in the minds of the [triers of fact] that the asserted facts are probably true."256 Providence relies on the EME report and deposition of Dr. Yodlowski, as well as the medical records and the record as a whole to argue first that the employee does not have any PPI or current disability or need for ongoing medical benefits, and second, that if the employee does have a PPI or current disability and resulting need for medical benefits, the work injury at First Student was the legal cause. Dr. Yodlowski has opined that the employee’s current low back condition is the result of her preexisting degenerative disc disease and not the result of any work injury, and further that the employee does not have an impairment or any restrictions on her activities. Providence also pointed to the medical records, in addition to Dr. Yodlowski’s testimony, claiming this information showed the employee’s pain from her work injury of December 2004 had resolved as early as February 10, 2005, for example. However, Dr. Yodlowski only examined the patient once and reviewed her medical records. Further, Dr. Yodlowski claimed the employee had degenerative disc disease preceding her work injury at Providence, but does not point to any medical evidence to support this conclusion. Dr. Yodlowski’s opinion concerning the employee’s preexisting degenerative disc disease is contradicted by the employee’s lack of any back problems or pain prior to the Providence work injury. In addition, Providence’s claim the employee was pain free by February 10, 2005 is contradicted by the medical records of that very date, specifically the progress notes of PT Young of UPT. This claim is also contradicted by an abundance of evidence in the medical records, as well as the testimony of the employee and her lay witnesses concerning her low back pain levels over time. We find the employee’s testimony and that of her witnesses concerning her pain levels over time credible. We find this testimony is probative especially for the period of time before the injury at First Student, as the employee was never evaluated by a medical doctor before her work injury at First Student and the health records at Providence by ANP Huffman are brief and contain little information concerning physical exams. We find Providence has failed to prove by a preponderance of the evidence either the work injury at First Student is the legal cause of the employee’s condition or that the employee’s current condition is not work related.

255 Wolfer, 693 P.2d at 870. 256 Saxton v. Harris, 395 P.2d 71, 72 (Alaska 1964).

In applying the two prong test of the last injurious exposure doctrine, articulated in Peek, we find the employee’s work at First Student caused a temporary exacerbation of her pre-existing low back condition. However, we find the exacerbation of the employee’s low back condition due to the First Student work injury resolved by the end of March of 2006. The Board finds the employee’s injury at First Student was not the substantial cause, or even a substantial factor, in bringing about the permanent harm caused by the low back condition. The Board finds the facts of this case do not satisfy the second prong of the Peek test. We conclude the employee’s work injury at First Student was not the cause of the employee’s PPI, current low back impairment and disability.

We are persuaded First Student is not the cause of the employee’s PPI and current low back condition by the preponderance of the medical evidence, especially the opinion of Dr. James, the employee’s treating physician, whose testimony we accord great weight, due to his treatment of the employee over time and thorough knowledge of her condition. Dr. James clearly recognizes the December 27, 2004 work injury at Providence as a pre-existing condition out of which the employee's present medical difficulties arose. Dr. James testified the employee's injury at First Student was no more than a transient exacerbation of her pre-existing injury at Providence. Dr. James also testified the employee did not have degenerative disc disease prior to her work injury at Providence and that it is unusual for a person of the employee’s age to have degenerative disc disease. Dr. James stated if a person of the employee’s age has disc herniations at two levels, it is because of antecedent trauma or injury. Even Providence’s EIME physician, Dr. Yodlowski, opined that the work injury at First Student caused only a temporary exacerbation of the employee’s low back condition. We find the employee’s injury at First Student had fully resolved to its pre- injury condition by the end of March 2006, before the claims for PPI and ongoing medical benefits the employee is now requesting, arose.

Under the last injurious exposure rule, we must now turn our attention to "the employer at the time of the most recent injury that bears a causal relation to the disability,"257 that is, to Providence. The record is clear that the employee suffered significant work-related injury during her employment

257 Saling, 604 P.2d at 595.

49 BETHANN M. JACKSON v. PROVIDENCE HEALTH SYSTEM v. FIRST STUDENT SERVICES with Providence on December 27, 2004. We find this evidence is sufficient to raise a presumption of compensability under AS 23.30.120(a) against that employer.258

As stated above, Providence relies on the EME report and deposition of Dr. Yodlowski, as well as the medical records and the record as a whole to argue first that the employee does not have any PPI or current disability or need for ongoing medical benefits, and second, that if the employee does have a PPI or current disability and resulting need for medical benefits, the work injury at First Student was the cause. Providence relied primarily on the testimony of Dr. Yodlowski to rebut this presumption. Dr. Yodlowski has opined that the employee’s current low back condition is the result of her preexisting degenerative disc disease and not the result of any work injury. Providence also pointed to the medical records, in addition to Dr. Yodlowski’s testimony, claiming this information showed the employee’s pain from her work injury of December 2004 had resolved as early as February 10, 2005, for example. However, Dr. Yodlowski only examined the patient once and reviewed her medical records. Further, Dr. Yodlowski claimed the employee had degenerative disc disease preceding her work injury at Providence, but does not point to any medical evidence to support this conclusion. Dr. Yodlowski’s opinion concerning the employee’s preexisting degenerative disc disease is contradicted by the employee’s lack of any back problems or pain prior to the Providence work injury. In addition, Providence’s claim the employee was pain free by February 10, 2005 is contradicted by the medical records of that very date, specifically the progress notes of PT Young of UPT. We find Providence has failed to provide substantial evidence to rebut the presumption. Additionally, even if we could find sufficient evidence to rebut the presumption of compensability, we would find the overwhelming preponderance of the evidence in the record indicates employee's December 27, 2004 work injury at Providence is a substantial cause of her PPI, current medical condition and disability.

In the instant case, the Board has reviewed the applicability of the last injurious exposure doctrine and, in view of our findings and conclusions set out above, the Board makes the following findings:

258 Smallwood, 623 P.2d at 316.

1. The Board finds at the time of the employee’s motor vehicle accident on February 18, 2005, the employee was suffering from low back pain from her December 27, 2004 injury at Providence. She had been placed on full duty, but her increasing pain levels, nine on a scale of one to ten, forced her back to light duty. The employee was also still receiving physical therapy for her injury at Providence. In addition, the employee’s injuries resulting from the motor vehicle accident were to her upper back and neck, not her low back.259 2. The Board finds that at the time the employee went to work at First Student in September of 2005, she was still suffering from the low back pain from her December 27, 2004 injury at Providence. The work injury the employee suffered at First Student on November 18, 2005 resulted in a temporary exacerbation of her low back pain, but by March of 2006, this pain decreased to the level it was before the injury at First Student. Therefore, when the employee suffered her work injury at First Student, the employee experienced a temporary exacerbation of her condition, which resolved back to the level it had been before the First Student work injury by March of 2006. 3. The Board finds that the employee’s current, persisting low back condition arose from employment at Providence. We must conclude Providence bears the liability for any benefits due to the employee under the Alaska Workers' Compensation Act.260

III. BENEFITS

A. PERMANENT PARTIAL IMPAIRMENT At the time of the employee's 2004 injury, AS 23.30.190 provides, in part: (a) in case of impairment partial in character but permanent in quality. . . the compensation is $177,000 multiplied by the employee's percentage of permanent impairment of the whole person. The compensation is payable in a single lump sum, except as otherwise provided in AS 23.30.041 . . . ."

(b) All determinations of the existence and degree of permanent impairment shall be made strictly and solely under the whole person determination as set out in the American Medical Association Guides to the Evaluation of Permanent Impairment . . .

259 Employee’s deposition, 9/14/07, pg. 19-20. 260 DeYonge, 1 P.3d at 96.

(c) The impairment rating determined under (a) of this section shall he reduced by a permanent impairment that existed before the compensable injury.

As noted earlier, the presumption of compensability applies to all claims for benefits.261 The presumption attaches if the employee makes a minimal showing of a preliminary link between the disability and employment.262

Applying the presumption analysis to the employee’s current low back condition and PPI, the Board finds the employee has raised the presumption of compensability based on Dr. James deposition testimony, the medical records, the employee’s own testimony, and that of the lay witnesses called on her behalf.

Once the claimant establishes the presumption of compensability, the burden shifts to the employer to rebut this presumption with substantial evidence. The Board examines the employer’s evidence in isolation to determine whether it has: (1) produced substantial evidence that provides an alternative explanation which, if accepted, would exclude work-related factors as a substantial cause of the disability; or (2) directly eliminated any reasonable possibility that the employment was a factor in the disability.263

Providence presented evidence from Dr. Yodlowski that the employee had pre-existing degenerative changes of her lumbosacral spine and the injury suffered by the employee due to the December 27, 2004 work injury was a lumbosacral sprain/strain, which caused only a temporary exacerbation of symptoms. She further stated the work injury of December 27, 2004, had completely resolved by three months time, but that its resolution was delayed somewhat by the motor vehicle accident of February 18, 2005, until the end of March, 2005.264 Dr. Yodlowski also opined the work injury at First Student on November 18, 2005, also only caused a temporary exacerbation of the employee’s pre-existing degenerative changes of her lumbosacral spine,

261 Meek, 914, P.2d at 1279-1280. 262 Olson, 818 P.2d at 675. 263 Grainger, 805 P.2d at 977. 264 Dr. Yodlowski amended this date to June 2005 in her August 2007 updated EME report.

52 BETHANN M. JACKSON v. PROVIDENCE HEALTH SYSTEM v. FIRST STUDENT SERVICES which would have resolved after three months time. Dr. Yodlowski performed a PPI rating on the employee and found a 0% impairment of the whole person.

The Board finds Dr. Yodlowski’s EME report and deposition testimony do not represent substantial evidence to rebut the presumption raised by the employee as to the employee’s current condition and impairment being related to work at Providence. In order to constitute reliable evidence, medical testimony cannot simply point to other possible causes of an employee’s injury or disability, without ruling out work related causes.265 In the instant case, Dr. Yodlowski conducted one evaluation of the employee, which according to the employee’s hearing testimony only lasted twenty minutes. Dr. Yodlowski also reviewed her medical records, and opined the employee’s condition was caused by underlying degenerative disc disease. Furthermore, Dr. Yodlowski’s determination the employee had underlying degenerative disc disease is contradicted by the results of the May 2005 MRI, which shows no evidence of significant degenerative disc disease, as well as Dr. James’ testimony. Dr. Yodlowski’s opinion, based on a one time in-person evaluation and review of medical records, cannot be considered to be comprehensive and reliable as required to rule out the employee’s work injury and resulting symptoms as a factor for her disability and need for continuing treatment.266 The Board concludes the employer has not rebutted the presumption of compensability of the employee’s current condition and impairment.

However, even if we find Dr. Yodlowski’s opinion is substantial evidence to rebut the presumption, we find the preponderance of the evidence shows the employee suffers a ratable permanent impairment from her work injury at Providence. Specifically, based on Dr. James testimony, and our review of the entire record, we find the employee’s low back condition was caused by the employee’s injury at Providence and was not permanently worsened by either the motor vehicle accident or the employee’s work at First Student. We further find, based on Dr. James testimony, the work injury at Providence was a substantial factor in bringing about the 16

265 Tolbert v. Alascom, Inc., 973 P.2d 603, 611 (Alaska 1999), citing Childs v. Cooper Village Electric Association, 860 P.2d 1184, 1189 (Alaska 1993). See also, Williams v. State, Dept. of Revenue, 930 P.2d 1065, 1075 (Alaska 1997). 266 Carlson v. Doyon Universal/Ogden Services, 995 P.2d 205 (Alaska 2000). See also, Black v. Universal Services, Inc., 627 P.2d 1073 (Alaska 1981).

53 BETHANN M. JACKSON v. PROVIDENCE HEALTH SYSTEM v. FIRST STUDENT SERVICES percent whole person permanent impairment Dr. James assessed. We also find, based on Dr. James testimony and the entire record, neither the work injury at First Student nor the motor vehicle accident was the substantial cause, or a substantial factor, in bringing about the 16 percent whole person impairment suffered by the employee.

Although Dr. Yodlowski testified in her deposition that in her opinion the employee suffered from pre-existing degenerative disc disease, and the work injury she sustained at Providence was only a temporary exacerbation of the pre-existing disease, we do not find the employee suffered from pre-existing degenerative disc disease prior to the work injury at Providence. This finding is based on the following: 1) Dr. James testimony that a person as young as the employee would not typically have degenerative disc disease or disc protrusions; 2) Dr. James testimony concerning the results of the serial MRI’s of May 2005 and November 2005, as well as the MRI reports themselves, that showed no significant degenerative disc disease in May 2005, but did show such disease on November 23, 2005, when also according to Dr. James’ testimony, such disease could not be attributed to the November 18, 2005 work injury a few days prior; and 3) the employee’s testimony that she had no back pain prior to the December 27, 2004 work injury.

Dr. Yodlowski also found the employee had a zero percent PPI. The Board finds that the employee has a 16% PPI of the whole person, based on Dr. James rating of the employee’s PPI. Dr. Yodlowski faulted Dr. James for using the ROM method to rate the employee’s impairment, as she opined at her deposition the employee did not have two-level involvement. Dr. Yodlowski first rational for her opinion was because MRI findings alone are not enough to make a diagnosis, but must be accompanied by a radiculopathy.267 We take administrative notice that the AMA Guides on page 378 state the following concerning clinical studies of the spine: While imaging and other studies may assist physicians in making a diagnosis, it is important to note that a positive imaging study in and of itself does not make the diagnosis. Several reports indicate approximately 30% of persons who have never had back pain will have an imaging study that can be interpreted as positive for a herniated disk, and 50% or more will have bulging disks. Further, the prevalence of degeneration changes, bulges, and herniations increases with advancing age. To be of diagnostic value, clinical symptoms and signs must agree with the imaging findings. In other words, an imaging test is useful to confirm a diagnosis, but an imaging result alone is insufficient to qualify for a

267 Dr. Yodlowski’s deposition, 10/31/07, pg. 29.

DRE category. Individuals with electromyography (EMG) studies that are clearly positive support a diagnosis of radiculopathy and therefore qualify for at least DRE category III.

We find that Dr. James relied on the employee’s history of work injuries, clinical symptoms and signs, such as low back pain and pain in the right buttock, and impaired mobility, as well as the findings on the MRI’s to determine that the employee had multi-level involvement. Therefore Dr. James use of the ROM method to assess the employee’s PPI was appropriate and a reasonable and permissible interpretation of the AMA Guides. In making this finding, we also rely on Dr. James deposition testimony that it is extremely atypical for women of 23 years of age to have disc protrusions at two levels, and when they do, there is antecedent trauma or injury.268

Dr. Yodlowski’s second rational was even if the employee had disc herniations at two levels, those disc herniations had to be accompanied by radiculopathy before use of the ROM method would be appropriate. Dr. Yodlowski relied in part on information from the website of Brigham & Associates for her interpretation of the AMA Guides as not permitting the use of the ROM method for evaluating the employee’s impairment due to the question of radiculopathy. The employee objected to the admission into the Board’s record of this internet material. The Board finds this internet material should be excluded from the record based on the employer’s inability to cross-examine the authors. This ruling is made in accordance with 8 AAC 45.120(c)(3), (f), (g) and (h) and the Alaska Supreme Court case Employer’s Commercial Union Insurance Group v. Schoen.269 The Board finds that even if the internet material was admitted and considered, the material simply represents the opinion of a physician on the interpretation of the AMA Guides, a physician who did not examine the employee. We find that Dr. James interpretation of the AMA Guides that to use the ROM method, disc herniations must be at two levels, but do not have to be accompanied by radiculopathy, is a reasonable and permissible interpretation of the AMA Guides.

Dr. Yodlowski also opined at her deposition that the employee’s symptoms of right buttock pain and right lower extremity pain were not radiculopathy. We find that Dr. James’ diagnosis of the

268 Dr. James’ deposition, 12/19/07, pg. 101-102. 269 Pratt v. Catholic Community Services, AWCB Decision No. 04-0170, July 14, 2004; Employer’s Commercial Union Insurance Group v. Schoen, 519 P.2d 819 (Alaska 1974).

55 BETHANN M. JACKSON v. PROVIDENCE HEALTH SYSTEM v. FIRST STUDENT SERVICES employee’s buttock and lower extremity pain as radiculopathy is a reasonable and permissible interpretation of the AMA Guides. Dr. Yodlowski conceded at her deposition that other doctors might agree that right buttock pain would be considered radiculopathy.

The Board also finds based on Dr. James rating of the employee’s impairment by the DRE method at 5%-8%, that the employee’s whole person impairment is 5-8% by the DRE method. Dr. Yodlowski stated at her deposition that she placed the employee in DRE lumbar category I, which has a 0% impairment, in part because the employee did not have asymmetric loss in range of motion, which she defined as there is some reason that when you’re bending forward or flexing back, the muscle spasm pulls you to the side.270 We take administrative notice of the following: 1. On page 382 of the AMA Guides, asymmetry of spinal motion is defined as follows: Asymmetric motion of the spine is one of the three principal planes is sometimes caused by muscle spasm or guarding. That is, if an individual attempts to flex the spine, he or she is unable to do so moving symmetrically; rather, the head or trunk leans to one side.271

2. On page 384 of the AMA Guides, under DRE Lumbar Category II, the person being rated must have a clinical history and examination findings that are compatible with a specific injury; findings may (emphasis added) include…asymmetric loss of range of motion (emphasis added), or nonverifiable radicular complaints.272

The Board takes administrative notice that the list of findings compatible with a specific injury is permissive, due to the use of the word “may”, not mandatory. Dr. James explained that he placed the employee in the DRE Lumbar Category II because of her clinical history and examination compatible with a specific injury, and findings which included asymmetric loss of range of motion.273 The Board finds that asymmetry of spinal motion and asymmetric loss of range of motion are not the same. The Board finds that Dr. James finding the employee suffered

270 Dr. Yodlowski’s 10/31/07 deposition, pgs. 30-32. 271 AMA Guides, pg. 382, Box 15-1. 272 AMA Guides, pg. 384, Table 15-3. 273 Dr. James’ 12/19/07 deposition, pgs. 21-22 and pgs. 83-84.

56 BETHANN M. JACKSON v. PROVIDENCE HEALTH SYSTEM v. FIRST STUDENT SERVICES a 5-8% whole person impairment by the DRE method is a reasonable and permissible interpretation of the AMA Guides.

The Board takes administrative notice that according to the AMA Guides on page 380 it states: In the small number of instances in which the ROM and DRE methods can both be used, evaluate the individual with both methods and award the higher rating.274

Considering all of the foregoing discussion on the appropriate PPI rating for the employee, the preponderance of the evidence shows, and the Board finds, the employee’s whole person impairment is 16%.

B. MEDICAL BENEFITS AND TRANSPORTATION EXPENSES AS 23.30.095(a) provides, in part: The employer shall furnish medical, surgical, and other attendance of treatment, nurse and hospital service, medicine, crutches, and apparatus for the period which the nature of the injury or the process of recovery requires....

8 AAC 45.082(d) provides in pertinent part: Unless the employer disputes the prescription charges or transportation expenses, an employer shall reimburse an employee's prescription charges or transportation expenses for medical treatment within 30 days after the employer receives . . . an itemization of the dates of travel and transportation expenses for each date of travel." The presumption of compensability under AS 23.30.120(a) also applies to claims for medical benefits.275 Treatment must be reasonable and necessary to be payable under subsection 95(a).276

In this case, the disputed medical treatment has been provided and recommended by employee’s treating physician, Dr. James, or the employee’s other health care providers, ANP Huffman, ANP Wilson and confirmed by the opinion of Providence’s EME physician, Dr. Yodlowski. Based on the medical reports and testimony of the employee’s health care providers, we find the record contains sufficient evidence to raise the presumption of compensability for the medical benefits claimed by the employee. In most circumstances, to overcome a presumption once it attaches, the

274 AMA Guides, pg. 380. 275 Municipality of Anchorage v. Carter, 818 P.2. 661, 665 (Alaska 1991). 276 See Weidner & Associates v. Hibdon, 989 P.2d 727, 731 (Alaska 1999).

57 BETHANN M. JACKSON v. PROVIDENCE HEALTH SYSTEM v. FIRST STUDENT SERVICES employer must present substantial evidence that the medical benefits claimed are not compensable.277

Providence presented the evidence from Dr. Yodlowski’s deposition and EME report that the employee does not suffer from any work-related permanent partial impairment, but only limitations due to a combination of her pre-existing and progressive degenerative disease of the lumbosacral spine and her general level of deconditioning and obesity. Dr. Yodlowski opined the employee had the physical capacity to perform the work of a CNA or a bus attendant two months after November 18, 2005. As stated previously, the Board finds the opinion of Dr. Yodlowski is not substantial evidence rebutting the presumption of compensability of the compensability of the employee’s ongoing medical treatment.

Even if we were to find the opinion of Dr. Yodlowski constituted substantial evidence, we find the opinions and medical reports of Dr. James, who treated the employee, particularly persuasive. Based on our review of the entire record, and especially the opinions and reports of Dr. James, we find the preponderance of the evidence shows the employee’s current low back condition and need for medical treatment is a result of her work-related injury at Providence.

We find Providence should pay medical benefits for the employee for the period from April, 2006 through June 20, 2006, and the period January 11, 2007 through February 8, 2007. Since these medical expenses have already been paid by Medicaid or First Student, Providence should reimburse Medicaid or First Student for those expenses. We find Providence should pay the employee for her medical transportation costs for the total mileage of 206.2 miles accumulated from December 27, 2004 up to November 18, 2005.

We find First Student should pay the employee for any medical expenses not yet paid, or paid by Medicaid for the period from November 18, 2005 through March 31, 2006. If any of these expenses have already been paid by Medicaid, First Student should reimburse Medicaid for those expenses.

277 Louisiana Pacific Corp. v. Koons, 816 P.2d 1379, 1381 (Alaska 1991); DeYonge, 1 P.3d at 96.

In addition, we find Providence should provide the employee with ongoing and future reasonable and necessary medical benefits for her low back condition.

C. TEMPORARY DISABILITY BENEFITS At the time of the employee's injury, the Alaska Workers' Compensation Act defined "disability" as "incapacity because of injury to earn the wages which the employee was receiving at the time of injury in the same or any other employment."278 The Act provided for benefits at 80% of the employee's spendable weekly wage while the disability is "total in character but temporary in quality,"279 but did not define TTD.

Nevertheless, the Alaska courts long ago defined TTD for its application in our cases. In Phillips Petroleum Co. v. Alaska Industrial Board,280 the Alaska territorial court defined TTD as "the healing period or the time during which the workman is wholly disabled and unable by reason of his injury to work." The court explained: A claimant is entitled to compensation for temporary total disability during the period of convalescence and during which time the claimant is unable to work, and the employer remains liable for total compensation until such time as the claimant is restored to the condition so far as his injury will permit. The test is whether the claimant remains incapacitated to do work by reason of his injury, regardless of whether the injury at some time can be diagnosed as a permanent partial disability. 17 Alaska at 666 (citations omitted).

In Vetter v. Alaska Workmen's Compensation Board,281 the Alaska Supreme Court stated: The concept of disability compensation rests on the premise that the primary consideration is not medical impairment as such, but rather loss of earning capacity related to that impairment. An award for compensation must be supported by a finding that the claimant suffered a compensable disability, or more precisely, a decrease in earning capacity due to a work-connected injury or illness.

The Alaska Supreme Court held "the text of AS 23.30.120(a)(1) indicates that the presumption of compensability is applicable to any claim for compensation under the workers' compensation

278 AS 23.30.265(16). 279 AS 23.30.185 280 Phillips Petroleum Co. v. Alaska Industrial Board, 17 Alaska 658, 665 (D. Alaska 1958) (quoting Gorman v. Atlantic Gulf & Pacific Co., 178 Md. 71, 12 A.2d 525, 529 (1940)) 281 Vetter, 524 P.2d 264, 266.

59 BETHANN M. JACKSON v. PROVIDENCE HEALTH SYSTEM v. FIRST STUDENT SERVICES statute."282 The presumption attaches if the employee makes a minimal showing of a preliminary link between the disability and employment.283 Also, a substantial aggravation of an otherwise unrelated condition, imposes full liability on the employer at the time of the most recent injury that bears a causal relation to the disability.284

We find the employee’s testimony concerning the development of her symptoms related to her low back injury, combined with that of Dr. James that her low back condition arose from the work injury at Providence, the injuries from the motor vehicle accident did not result in an injury to her low back, and the injury at First Student resulted in a temporary exacerbation of the employee’s low back condition, is sufficient to raise the presumption that she suffered a compensable injury and disability. Following the court’s rationale in Meek, we must apply the presumption of compensability from AS 23.30.120(a)(1) to the temporary disability benefits she claims following December 27, 2004 injury.

We find the evidence Providence submitted by Providence in the form of Dr. Yodlowski’s opinion the employee’s disability from the December 27, 2004 injury would have resolved three months after the injury, but was prolonged until June, 2005 by the motor vehicle accident, is not substantial evidence rebutting the presumption.285 We find Dr. Yodlowski’s opinion does not constitute substantial evidence as Dr. Yodlowski only saw the patient one time and reviewed her medical records and because her opinion is based in large part on her belief the employee had significant degenerative disc disease preexisting her work injury at Providence. We have found Dr. Yodlowski’s opinion concerning the employee’s preexisting disc disease to be unfounded, as the May 2005 MRI of the employee’s lumbar spine showed no degenerative disc disease and because of Dr. James’ professional opinion it is very atypical for a person as young as the employee to have degenerative disc disease. However, even if we found Dr. Yodlowski’s opinion is substantial evidence to rebut the presumption, we find the preponderance of the evidence in the record as a whole, particularly the opinion of the treating physician Dr. James, but also the testimony of the

282 Meek v. Unocal Corp., 914 P.2d 1276, 1279 (Alaska 1996), (quoting Municipality of Anchorage v. Carter, 818 P.2d 661, 665 (Alaska 1991)). 283 Olson v. AIC/Martin J.V., 818 P.2d 669, 675 (Alaska 1991). 284 Peek, 855 P.2d at 4163); 9 A. Larson, The Law of Worker's Compensation, § 95.12 (1997). 285 Grainger, 805 P.2d at 977. See also, Black v. Universal Services, Inc., 627 P.2d 1073, 107-1077 (Alaska 1981).

60 BETHANN M. JACKSON v. PROVIDENCE HEALTH SYSTEM v. FIRST STUDENT SERVICES employee and her lay witnesses concerning her lack of back pain prior to the Providence work injury, level of back pain both before and after her work injuries and the motor vehicle accident, and ongoing back pain, and the record as a whole, proves the patient was entitled to TTD from Providence for the periods from December 27, 2004 through January 2, 2005 and February 26, 2005 through July 30, 2005 and August 1, 2005 through September 8, 2005 or September 28, 2005, whenever the employee started work at First Student.

We find the employee is owed TTD by Providence in the amount of $340.57 for the period of time from December 27, 2004 to January 2, 2005. We find the employee sought and obtained unemployment benefits from February 26, 2005 through July 30, 2005. The employee argues Providence should pay the employee temporary partial disability for the period from February 26, 2005 to July 30, 2005 in the amount of $184.41 per week or $4,075.46 to be paid her as the differential between her TTD rate and her unemployment benefit rate.286 We take administrative notice that under AS 23.30.187, the Act does not allow the payment of TPD or TTD to the employee for any period of time the injured worker receives unemployment.287 We find the employee’s claim for TPD and TTD benefits during the period from February 26, 2005 through July 30, 2005 must be denied and dismissed.

We also find Providence should pay the employee TTD benefits from August 1, 2005 through September 8th or September 28th, 2005, whenever she started work at First Student, in the amount of $340.57 per week, or a total of $1,873.16 or $2,894.85, respectively. We find there is contradictory evidence in the record concerning when the employee began work at First Student, since the employee testified at hearing she thought her start date at First Student was September 28, 2005 and First Student stated in its hearing brief it was on September 8, 2005.

Based on the representations made at hearing by Ms. Davison and Mr. Jensen, we find the employee’s claim against First Student for TTD from November 18, 2005 through November 27, 2005, has already been paid with interest.

286 See, Alyeska Pipeline Service Co. v. DeShong, 77 P.3rd 1227 (Alaska 2003). 287 AS 23.30.187 provides: Effect of unemployment benefits. Compensation is not payable to an employee under AS 23.30180 or 23.30.185 for a week in which the employee receives unemployment benefits.

Additionally, based on the employee’s own testimony we find First Student complied with the requirements of the Act in providing the employee with reasonable and necessary medical care for the duration of her temporary aggravation following her injury. Therefore, we conclude the employee’s claim against First Student for attorney fees and legal costs must be denied and dismissed.

D. INTEREST 8 AAC 45.140 provides, in pertinent part: Interest. (a) If compensation is not paid when due, interest must be paid …at the rate established in AS 09.30.070(a) for an injury that occurred on or after July 1, 2000. If more than one installment of compensation is past due, interest must be paid from the date each installment of compensation was due, until paid. If compensation for a past period is paid under an order issued by the board, interest on the compensation awarded must be paid from the due date of each unpaid installment of compensation. (b) The employer shall pay the interest (1) on late-paid time-loss compensation to the employee, or if deceased, to the employee’s beneficiary or estate; …. (3) on late-paid medical benefits to (A) the employee or, if deceased, to the employee’s beneficiary or estate, if the employee has paid the provider or the medical benefits; (B) to an insurer, trust, organization, or government agency, if the insurer, trust, organization, or government agency has paid the provider of the medical benefits; or (C) to the provider if the medical benefits have not been paid.

AS 23.30.155(p) provides: An employer shall pay interest on compensation that is not paid when due. Interest is required under this subsection accrues at the rate specified in AS 09.30.070(a) that is in effect on the date the compensation is due.

For injuries which occurred on or after July 1, 2000, AS 23.30.155(p) and our regulation at 8 AAC 45.142 requires the payment of interest at a statutory rate, as provided at AS 09.30.070(a), from the date at which each installment of compensation, including medical compensation, is due. The Courts have consistently instructed us to award interest to claimants for the time-value

62 BETHANN M. JACKSON v. PROVIDENCE HEALTH SYSTEM v. FIRST STUDENT SERVICES of money, as a matter of course.288 We find interest should be paid at the statutory rate for the loss of the time value of the benefits pursuant to 8 AAC 45.142, AS 23.30.155(p) and AS 09.30.070(a).

IV. ATTORNEY’S FEES AND COSTS AS 23.30.145 states, in pertinent part: (a) Fees for legal services rendered in respect to a claim are not valid unless approved by the board, and the fees may not be less than 25 percent on the first $1,000 of compensation or part of the first $1,000 of compensation, and 10 percent of all sums in excess of $1,000 of compensation. When the board advises that a claim has been controverted, in whole or in part, the board may direct that the fees for legal services be paid by the employer or carrier in addition to compensation awarded; the fees may be allowed only on the amount of compensation controverted and awarded. . . . (b) If an employer fails to file timely notice of controversy or fails to pay compensation or medical and related benefits within 15 days after it becomes due or otherwise resists the payment of compensation or medical and related benefits and if the claimant has employed an attorney in the successful prosecution of the claim, the board shall make an award to reimburse the claimant for the costs in the proceedings, including a reasonable attorney fee. The award is in addition to the compensation or medical and related benefits ordered.

The employee is seeking actual attorney fees under AS 23.30.145(b). The Alaska Supreme Court noted in Williams v. Abood289 as follows: We have held that awards of attorney's fees under AS 23.30.145 "should be fully compensatory and reasonable, in order that injured workers have competent counsel available to them." However, this does not mean that an attorney representing an injured employee in front of the board automatically gets full, actual fees. We held in Bouse v. Fireman's Fund Insurance Co. that an employee is entitled to "full reasonable attorney's fees for services performed with respect to issues on which the worker prevails." (Footnote omitted)

Further, the award of attorney fees and costs must reflect the contingent nature of workers’ compensation proceedings.

288 See Land & Marine Rental Co. v. Rawls, 686 P.2d 1187 at 1192 (Alaska 1987); Childs v. Copper Valley Electric Assn. et al, 860 P.2d 1184 at 1191 (Alaska 1993)(quoting Moretz v. O'Neill Investigations, 783 P.2d 764, 765-66 (Alaska 1989). 289 53 P.3d 134,147 (Alaska 2002).

As we have noted, the objective of awarding attorney's fees in compensation cases is to ensure that competent counsel are available to represent injured workers. Wien Air Alaska v. Arant, 592 P.2d at 365-66. This objective would not be furthered by a system in which claimants' counsel could receive nothing more than an hourly fee when they win while receiving nothing at all when they lose.290

The employee submitted statements of itemized attorney fees at the rate of $295.00 per hour for the work done through December 31, 2007, and $315.00 per hour for the work done in 2008.

Based on our review of the record, we find the employer controverted the employee’s claim, and the employee’s attorney has successfully obtained benefits for the employee. Specifically, we find the employee’s attorney effectively prosecuted the employee’s entitlement to benefits. The Board concludes we may award attorney's fees under AS 23.30.145(b).

AS 23.30.145(b) requires the award of attorney's fee and costs be reasonable. Our regulation 8 AAC 45.180(d) requires a fee awarded under AS 23.30.145(b) be reasonably commensurate with the work performed. It also requires that the Board consider the nature, length and complexity of the services performed, as well as the amount of benefits involved. In our awards, the Board attempts to recognize the experience and skills exercised on behalf of injured workers, and to compensate the attorneys accordingly.291

In light of these factors, we have examined the record of this case. The employee’s affidavits of fees and costs and statement at the hearing itemize the following for Attorney Michael Jensen: 1) 108.3 hours of attorney time at $295.00 per hour, and 17.10 hours at $315.00 per hour, totaling $37,335.00; 2) 70.8 hours of paralegal time at $125.00 per hour, and 3 hours at $135.00 per hour, totaling $9,255.00; and costs totaling $2,011.78. Thus, the total fees and costs for Attorney Mike Jensen is $48,601.78.

We note the claimed hourly rate of $295.00 and $315.00 is within the reasonable range for experienced employees’ counsel in other cases,292 based on expertise and years of experience. We

290 Wise Mechanical Contractors v. Bignell, 718 P.2d 971, 975 (Alaska 1986). 291 See, Id., at 974; and Gertlar v. H & H Contractors, Inc., AWCB Decision No. 97-0105 (June 2, 1997). 292 See, e.g. Irby v. Fairbanks Gold Mining, AWCB Decision No. 05-0234 (September 12, 2005); Adkins v. Alaska Job Corp Center, AWCB Decision No. 07-0128 (May 16, 2007); Iversen v. Terrasond, Ltd., AWCB Decision No.

64 BETHANN M. JACKSON v. PROVIDENCE HEALTH SYSTEM v. FIRST STUDENT SERVICES found the employee counsel’s brief and arguments at hearing of great benefit to us in considering the disputes in this matter. We find this was a contested case, and this hourly rate is reasonable. We will award actual attorney fees at the rate of $295.00 and $315.00 per hour, paralegal fees at $125.00 and $135.00 per hour, and costs of $2,011.78. Having considered the nature, length, and complexity of the services performed, the resistance of the employer, as well as the amount of benefits resulting from the services obtained, we find the above-mentioned attorney fees reasonable for the successful prosecution of the employee’s claim for benefits. We will award a total of $48,601.78 as reasonable actual attorney fees, paralegal fees, and costs.

V. ATTORNEY FEES AND COSTS FOR FIRST STUDENT

AS 23.30.155(d) states, in relevant part: If the employer controverts the right to compensation, the employer shall file with the division and send to the employee a notice of controversion on or before the 21st day after the employer has knowledge of the alleged injury or death. If the employer controverts the right to compensation after payments have begun, the employer shall file with the division and send to the employee a notice of controversion within seven days after an installment of compensation payable without an award is due. When payment of temporary disability benefits is controverted solely on the grounds that another employer or another insurer of the same employer may be responsible for all or a portion of the benefits, the most recent employer or insurer who is party to the claim and who may be liable shall make the payments during the pendency of the dispute. When a final determination of liability is made, any reimbursement required, including interest at the statutory rate, and all costs and attorney fees incurred by the prevailing employer, shall be made within 14 days of the determination.

Under AS 23.30.155(d) First Student petitioned for reimbursement of attorney fees from Providence. AS 23.30.155(d) requires a liable employer to reimburse attorney fees and costs in a last injurious exposure dispute to an employer which prevails in showing itself not liable for an employee’s claimed benefits. Although Providence argues that the provision concerning attorneys’ fees and costs refers only to temporary disability benefits, we find that this argument does not have merit. The Alaska Supreme Court case the Board finds pivotal in the instant matter is Bouse v. Fireman’s Fund Ins. Co.293 We find the Supreme Court directs the Board to consider the two sentences of AS 23.30.155(d) separately; that the last sentence stands independently of all other sentences. In the instant matter, the employee filed WCC’s against both Providence and First

07-0350(November 19, 2007). 293 Bouse v. Fireman’s Fund Ins. Co., 932 P.2d 222, 240-241 (Alaska 1997).

Student. Providence filed three controversions, the first denying medical benefits past May 24, 2005, the second denying medical benefits past March 27, 2005, and the third denying all benefits. Based upon the Supreme Court's directive that the last sentence of AS 23.30.155(d) stands alone, and applies when medical benefits as well as other benefits are denied, and since the Board has made a final determination of liability, First Student is entitled to attorney’s fees.

First Student submitted affidavits itemizing and claiming $14,647.50 in actual attorney fees, $10,944.00 in paralegal costs, and $4,501.58 in legal costs. We made a final determination of liability, and under the plain terms of AS 23.30.155(d), we must award First Student these fees and costs.

ORDER I. Providence is ordered to pay compensation to the employee, her attorney and First Student as follows: 1. Temporary Total Disability from December 27, 2004 through January 2, 2005, in the amount of $340.57, plus interest, and from August 1, 2005 through September 8, 2005 or September 28, 2005, whichever date she started her employment with First Student, at the rate of $340.57 per week, in the amount of either $1,873.16 or $2,894.85, respectively. 2. Permanent Partial Impairment for a 16 percent whole person impairment in the amount of $177,000 X 16%, or $28,320.00. 3. Medical benefits after March of 2006. 4. Continue to provide reasonable and necessary medical care. 5. Attorney fees and costs to Mr. Jensen in the amount of $48,601.48. 6. First Student’s defense attorney fees for Ms. Davison’s work in the amount of $30,093.08. 7. Any interest due on late benefits.

II. In addition Providence is ordered to pay the employee or reimburse Medicaid, as circumstances require, for the following:

1. Any unpaid work related medical expenses for the period from April, 2006 through June 20, 2006, and the period January 11, 2007 through February 8, 2007, plus interest.

III. Providence is also ordered to reimburse First Student for the following: 1. Any medical expenses paid after March 2006.

IV. First Student is ordered to pay the employee or reimburse Medicaid, as circumstances require, for the following: 1. Any unpaid work related medical expenses for the period from November 23, 2005 through March 31, 2006. 2. Any interest due on late benefits.

Dated at Anchorage, Alaska on April 15, 2008.

ALASKA WORKERS' COMPENSATION BOARD

Pat Vollendorf, Member

Janet Waldron, Member

APPEAL PROCEDURES This compensation order is a final decision. It becomes effective when filed in the office of the Board unless proceedings to appeal it are instituted. Effective November 7, 2005 proceedings to appeal must be instituted in the Alaska Workers’ Compensation Appeals Commission within 30 days of the filing of this decision and be brought by a party in interest against the Board and all other parties to the proceedings before the Board. If a request for reconsideration of this final decision is timely filed with the Board, any proceedings to appeal must be instituted within 30 days after the reconsideration decision is mailed to the parties or within 30 days after the date the reconsideration request is considered denied due to the absence of any action on the reconsideration request, whichever is earlier. AS 23.30.127

An appeal may be initiated by filing with the office of the Appeals Commission: (1) a signed notice of appeal specifying the board order appealed from and 2) a statement of the grounds upon which

68 BETHANN M. JACKSON v. PROVIDENCE HEALTH SYSTEM v. FIRST STUDENT SERVICES the appeal is taken. A cross-appeal may be initiated by filing with the office of the Appeals Commission a signed notice of cross-appeal within 30 days after the board decision is filed or within 15 days after service of a notice of appeal, whichever is later. The notice of cross-appeal shall specify the board order appealed from and the grounds upon which the cross-appeal is taken. AS 23.30.128

RECONSIDERATION A party may ask the Board to reconsider this decision by filing a petition for reconsideration under AS 44.62.540 and in accordance with 8 AAC 45.050. The petition requesting reconsideration must be filed with the Board within 15 days after delivery or mailing of this decision.

MODIFICATION Within one year after the rejection of a claim, or within one year after the last payment of benefits under AS 23.30.180, 23.30.185, 23.30.190, 23.30.200, or 23.30.215, a party may ask the Board to modify this decision under AS 23.30.130 by filing a petition in accordance with 8 AAC 45.150 and 8 AAC 45.050.

CERTIFICATION I hereby certify that the foregoing is a full, true and correct copy of the Final Decision and Order in the matter of BETHANN M. JACKSON employee / applicant; v. PROVIDENCE HEALTH SYSTEM (self-insured) employer; v. FIRST STUDENT SERVICES, employer, and AMERICAN HOME ASSURANCE CO, insurer / defendants; Case No(s). 200422387, 200519911; dated and filed in the office of the Alaska Workers' Compensation Board in Anchorage, Alaska, on April 15, 2008.

Robin Burns, Administrative Clerk II.